Methods and devices for follow-up care and treatment of a pneumostoma

ABSTRACT

A pneumostoma assessment and treatment system includes methods and devices for aftercare of a pneumostoma and for additional patient care utilizing a pneumostoma. The system utilizes a number of modalities to assess the health and functionality of the pneumostoma, the lungs and/or the patient as a whole. In response to an assessment of the health and functionality of the pneumostoma, lungs and patient, the tissues of pneumostoma may be treated with a treatment device and utilizing one or more different modalities to preserve or enhance the health and function of the pneumostoma and/or treat other conditions of the patient.

CLAIM TO PRIORITY

This application claims priority to all of the following applicationsincluding: U.S. Provisional Application No. 61/029,830, filed Feb. 19,2008, entitled “ENHANCED PNEUMOSTOMA MANAGEMENT DEVICE AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06013US0);

U.S. Provisional Application No. 61/032,877, filed Feb. 29, 2008,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FOR TREATMENT OFCHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06001US0);

U.S. Provisional Application No. 61/038,371, filed Mar. 20, 2008,entitled “SURGICAL PROCEDURE AND INSTRUMENT TO CREATE A PNEUMOSTOMA ANDTREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06000US0);

U.S. Provisional Application No. 61/082,892, filed Jul. 23, 2008,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM HAVING A COSMETIC AND/ORPROTECTIVE COVER” (Attorney Docket No. LUNG1-06008US0);

U.S. Provisional Application No. 61/083,573, filed Jul. 25, 2008,entitled “DEVICES AND METHODS FOR DELIVERY OF A THERAPEUTIC AGENTTHROUGH A PNEUMOSTOMA” (Attorney Docket No. LUNG1-06003US0);

U.S. Provisional Application No. 61/084,559, filed Jul. 29, 2008,entitled “ASPIRATOR FOR PNEUMOSTOMA MANAGEMENT” (Attorney Docket No.LUNG1-06011US0);

U.S. Provisional Application No. 61/088,118, filed Aug. 12, 2008,entitled “FLEXIBLE PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06004US0);

U.S. Provisional Application No. 61/143,298, filed Jan. 8, 2009,entitled “METHODS AND APPARATUS FOR THE CRYOTHERAPY CREATION ORRE-CREATION OF PNEUMOSTOMY” (Attorney Docket No. LUNG1-06006US0); and

U.S. Provisional Application No. 61/151,581, filed Feb. 11, 2009,entitled “SURGICAL INSTRUMENTS AND PROCEDURES TO CREATE A PNEUMOSTOMAAND TREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06002US0).

All of the afore-mentioned applications are incorporated herein byreference in their entireties.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is related to all of the above provisional applicationsand all the patent applications that claim priority thereto including:

This application is related to all of the following applicationsincluding U.S. patent application Ser. No. 12/______, filed Feb. 18,2009, entitled “ENHANCED PNEUMOSTOMA MANAGEMENT DEVICE AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06013US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FOR TREATMENT OFCHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06001US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “PNEUMOSTOMA MANAGEMENT METHOD FOR TREATMENT OF CHRONICOBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No. LUNG1-06001US2);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “TWO-PHASE SURGICAL PROCEDURE FOR CREATING A PNEUMOSTOMA TOTREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06000US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “ACCELERATED TWO-PHASE SURGICAL PROCEDURE FOR CREATING APNEUMOSTOMA TO TREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (AttorneyDocket No. LUNG1-06000US2);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “SINGLE-PHASE SURGICAL PROCEDURE FOR CREATING A PNEUMOSTOMA TOTREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06000US3);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “PERCUTANEOUS SINGLE-PHASE SURGICAL PROCEDURE FOR CREATING APNEUMSOTOMA TO TREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (AttorneyDocket No. LUNG1-06000US4);

U.S. patent application Ser. No. 12/______, filed Feb. 13, 2009,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM HAVING A COSTMETIC AND/ORPROTECTIVE COVER” (Attorney Docket No. LUNG1-06008US1)

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “DEVICES AND METHODS FOR DELIVERY OF A THERAPEUTIC AGENTTHROUGH A PNEUMOSTOMA” (Attorney Docket No. LUNG1-06003US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “ASPIRATOR FOR PNEUMOSTOMA MANAGEMENT” (Attorney Docket No.LUNG1-06011US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “ASPIRATOR AND METHOD FOR PNEUMOSTOMA MANAGEMENT” (AttorneyDocket No. LUNG1-06011US2);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “FLEXIBLE PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06004US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “SURGICAL INSTRUMENTS FOR CREATING A PNEUMOSTOMA AND TREATINGCHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06002US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “ONE-PIECE PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06017US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM WITH SECRETION MANAGEMENTFEATURES FOR TREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE”(Attorney Docket No. LUNG1-06019US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “MULTI-LAYER PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULJMONARY DISEASE” (Attorney DocketNo. LUNG1-06022US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “VARIABLE LENGTH PNEUMOSTOMA MANAGEMENT SYSTEM FOR TREATMENT OFCHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06023US1); and

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “SELF-SEALING DEVICE AND METHOD FOR DELIVERY OF A THERAPEUTICAGENT THROUGH A PNEUMOSTOMA” (Attorney Docket No. LUNG1-06025US1).

All of the afore-mentioned applications are incorporated herein byreference in their entireties. This patent application also incorporatesby reference all patents, applications, and articles discussed and/orcited herein.

BACKGROUND OF THE INVENTION

In the United States alone, approximately 14 million people suffer fromsome form of Chronic Obstructive Pulmonary Disease (COPD). However anadditional ten million adults have evidence of impaired lung functionindicating that COPD may be significantly underdiagnosed. The cost ofCOPD to the nation in 2002 was estimated to be $32.1 billion. Medicareexpenses for COPD beneficiaries were nearly 2.5 times that of theexpenditures for all other patients. Direct medical services accountedfor $18.0 billion, and indirect cost of morbidity and prematuremortality was $14.1 billion. COPD is the fourth leading cause of deathin the U.S. and is projected to be the third leading cause of death forboth males and females by the year 2020.

Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease ofthe airways that is characterized by a gradual loss of lung function. Inthe United States, the term COPD includes chronic bronchitis, chronicobstructive bronchitis, and emphysema, or combinations of theseconditions. In emphysema the alveoli walls of the lung tissue areprogressively weakened and lose their elastic recoil. The breakdown oflung tissue causes progressive loss of elastic recoil and the loss ofradial support of the airways which traps residual air in the lung. Thisincreases the work of exhaling and leads to hyperinflation of the lung.When the lungs become hyperinflated, forced expiration cannot reduce theresidual volume of the lungs because the force exerted to empty thelungs collapses the small airways and blocks air from being exhaled. Asthe disease progresses, the inspiratory capacity and air exchangesurface area of the lungs is reduced until air exchange becomesseriously impaired and the individual can only take short shallowlabored breaths (dyspnea).

The symptoms of COPD can range from the chronic cough and sputumproduction of chronic bronchitis to the severe disabling shortness ofbreath of emphysema. In some individuals, chronic cough and sputumproduction are the first signs that they are at risk for developing theairflow obstruction and shortness of breath characteristic of COPD. Withcontinued exposure to cigarettes or noxious particles, the diseaseprogresses and individuals with COPD increasingly lose their ability tobreathe. Acute infections or certain weather conditions may temporarilyworsen symptoms (exacerbations), occasionally where hospitalization maybe required. In others, shortness of breath may be the first indicationof the disease. The diagnosis of COPD is confirmed by the presence ofairway obstruction on testing with spirometry. Ultimately, severeemphysema may lead to severe dyspnea, severe limitation of dailyactivities, illness and death.

There is no cure for COPD or pulmonary emphysema, only varioustreatments for ameliorating the symptoms. The goal of current treatmentsis to help people live with the disease more comfortably and to preventthe progression of the disease. The current options include: self-care(e.g., quitting smoking), therapeutic agents (such as bronchodilatorswhich do not address emphysema physiology), long-term oxygen therapy,and surgery (lung transplantation and lung volume reduction surgery).Lung Volume Reduction Surgery (LVRS) is an invasive procedure primarilyfor patients who have a localized (heterogeneous) version of emphysema;in which, the most diseased area of the lung is surgically removed toallow the remaining tissue to work more efficiently. Patients withdiffuse emphysema cannot be treated with LVRS, and typically only havelung transplantation as an end-stage option. However, many patients arenot candidates for such a taxing procedure.

A number of less-invasive surgical methods have been proposed forameliorating the symptoms of COPD. In one approach new windows areopened inside the lung to allow air to more easily escape from thediseased tissue into the natural airways. These windows are kept openwith permanently implanted stents. Other approaches attempt to seal offand shrink portions of the hyperinflated lung using chemical treatmentsand/or implantable plugs. However, these proposals remain significantlyinvasive and are still in clinical trails. None of the surgicalapproaches to treatment of COPD has been widely adopted. Therefore, alarge unmet need remains for a medical procedure that can sufficientlyalleviate the debilitating effects of COPD and emphysema and is acceptedby physicians and patients.

SUMMARY OF THE INVENTION

In view of the disadvantages of the state of the art, Applicants havedeveloped a method for treating COPD in which an artificial passagewayis made through the chest wall into the lung. An anastomosis is formedbetween the artificial passageway and the lung by pleurodesis betweenthe visceral and parietal membranes surrounding the passageway as itenters the lung. The pleurodesis creates an adhesion between the pleuralmembrane surrounding the passageway which prevents air from entering thepleural cavity and causing a pneumothorax (deflation of the lung due toair pressure in the pleural cavity). Pleurodesis results from a fibrotichealing response between the pleural membranes and may be localized tothe vicinity of the passageway. The artificial passageway through thechest wall also becomes epithelialized. The result is a stableartificial aperture through the chest wall which communicates with theparenchymal tissue of the lung.

The artificial aperture into the lung through the chest is referred toherein as a pneumostoma. The pneumostoma provides an extra pathway thatallows air to exit the lung while bypassing the natural airways whichhave been impaired by COPD and emphysema. By providing this ventilationbypass, the pneumostoma allows the stale air trapped in the lung toescape from the lung thereby shrinking the lung (reducinghyperinflation). By shrinking the lung, the ventilation bypass reducesbreathing effort, reduces expiratory pressures, reduces dyspnea, andallows more fresh air to be drawn in through the natural airways andincreases the effectiveness of all of the tissues of the lung for gasexchange. Increasing the effectiveness of gas exchange allows forincreased absorption of oxygen into the bloodstream and also increasedremoval of carbon dioxide. Reducing the amount of carbon dioxideretained in the lung reduces hypercapnia which also reduces dyspnea. Thepneumostoma thereby achieves the advantages of lung volume reductionsurgery without surgically removing or sealing off a portion of the lungor transplanting a lung.

The present invention provides methods and devices for assessing, andtreating the health and functionality of a pneumostoma. Utilizing themethods and devices of the present invention a physician can enhance thehealth, patency and/or effectiveness of a pneumostoma thereby enhancingthe remediation of COPD. Other objects, features and advantages of theinvention are apparent from drawings and detailed description to follow.

BRIEF DESCRIPTION OF THE DRAWINGS

The above and further features, advantages and benefits of the presentinvention are apparent upon consideration of the present descriptiontaken in conjunction with the accompanying drawings.

FIG. 1A shows the chest of a patient indicating alternative locationsfor a pneumostoma that may be managed using the devices and methods ofthe present invention.

FIG. 1B shows a sectional view of the chest illustrating therelationship between the pneumostoma, lung and natural airways.

FIG. 1C shows a detailed sectional view of a pneumostoma.

FIG. 1D shows a perspective view of a pneumostoma management device.

FIG. 1E shows the chest of a patient showing the pneumostoma managementdevice positioned at alternative pneumostoma locations.

FIG. 1F shows a detailed sectional view of a pneumostoma managementdevice positioned inside a pneumostoma.

FIG. 2A is a flow chart illustrating general steps for follow-up careand assessment of a patient having a pneumostoma according to anembodiment of the invention.

FIG. 2B is a flow chart illustrating general steps for follow-up careand treatment of a patient having a pneumostoma according to anembodiment of the invention.

FIG. 3A shows an exterior view of an instrument for internal inspectionof a pneumostoma according to an embodiment of the invention.

FIG. 3B shows a sectional view of the instrument for internal inspectionof a pneumostoma of FIG. 3A positioned within a pneumostoma.

FIG. 3C shows an exterior view of an alternative instrument for internalinspection of a pneumostoma according to an embodiment of the invention.

FIG. 3D is a flow chart illustrating steps for examination of apneumostoma with a pneumoscope according to an embodiment of theinvention.

FIG. 4A shows a view of a spirometry system for assessing thefunctionality of a pneumostoma according to an embodiment of the presentinvention.

FIG. 4B shows a view of a gas analysis system for assessing thefunctionality of a pneumostoma according to an embodiment of the presentinvention.

FIG. 4C shows a view of lung imaging system for imaging gas diffusionfrom a pneumostoma according to an embodiment of the present invention.

FIG. 4D and 4E show views of a diagnostic device for deliveringdiagnostic gas to a pneumostoma or sampling gas from a pneumostomaaccording to embodiments of the present invention.

FIGS. 5A-5C show views of a device for cleaning and treating thepneumostoma according to an embodiment of the invention.

FIG. 5D is a flow chart illustrating steps for treatment of apneumostoma with suction, irrigation and/or lavage according to anembodiment of the invention.

FIG. 6A shows a view of an ultrasound device for cleaning or treatingthe pneumostoma according to an embodiment of the invention.

FIG. 6B shows a view of a sound-wave therapy device for cleaning ortreating the pneumostoma according to an embodiment of the invention.

FIG. 6C is a flow chart illustrating steps for treatment of apneumostoma with sound and/or ultrasound according to an embodiment ofthe invention.

FIGS. 7A-7D show views of a mechanical instrument for dilating thepneumostoma or a portion of the pneumostoma according to an embodimentof the present invention.

FIG. 7E is a flow chart illustrating steps for treatment of apneumostoma with a mechanical instrument for dilating the pneumostomaaccording to an embodiment of the invention.

FIG. 7F shows an alternative mechanical instrument for dilating thepneumostoma or a portion of the pneumostoma according to an embodimentof the present invention.

FIG. 7G shows an alternative mechanical instrument for dilating thepneumostoma or a portion of the pneumostoma according to an embodimentof the present invention.

FIGS. 8A-8C show views of a thermotherapy device for treating tissues ofa pneumostoma according to an embodiment of the present invention.

FIGS. 8D-8E show views of an alternate thermotherapy device for treatingtissues of a pneumostoma according to an embodiment of the presentinvention.

FIGS. 9A-9B show views of an electromagnetic treatment device fortreating tissues of the pneumostoma according to an embodiment of thepresent invention.

FIG. 9C shows a view of an alternate electromagnetic treatment devicefor treating tissues of the pneumostoma according to an embodiment ofthe present invention.

FIG. 9D shows a view of an alternate electromagnetic treatment devicefor treating tissues of the pneumostoma according to an embodiment ofthe present invention.

DETAILED DESCRIPTION OF THE INVENTION

The following description is of the best modes presently contemplatedfor practicing various embodiments of the present invention. Thedescription is not to be taken in a limiting sense but is made merelyfor the purpose of describing the general principles of the invention.The scope of the invention should be ascertained with reference to theclaims. In the description of the invention that follows, like numeralsor reference designators are used to refer to like parts or elementsthroughout. In addition, the first digit of a reference numberidentifies the drawing in which the reference number first appears.

Pneumostoma Formation and Anatomy

FIG. 1A shows the chest of a patient identifying alternative locationsfor creating a pneumostoma that may be managed using the system of thepresent invention. A first pneumostoma 110 is shown on the front of thechest 100 over the right lung 101 (shown in dashed lines). Thepneumostoma is preferably positioned over the third intercostal space onthe mid-clavicular line. Thus the pneumostoma 110 is located on thefront of the chest between the third and fourth ribs. Although thepneumostoma 110 is preferably located between two ribs, in alternativeprocedures a pneumostoma can also be prepared using a minithoracotomywith a rib resection.

In FIG. 1A a second pneumostoma 112 is illustrated in a lateral positionentering the left lung 103 (shown in dashed lines). The pneumostoma 112is preferably positioned over the fourth or fifth intercostal spaceunder the left arm 104. In general, one pneumostoma per lung is created;however, more or less than one pneumostoma per lung may be createddepending upon the needs of the patient. In most humans, the lobes ofthe lung are not completely separate and air may pass between the lobes.The upper lobe is the preferred location for a pneumostoma as the upperlobe tends to move less during breathing. However depending upon thepatient, it may be desirable to position a pneumostoma in any one of thelobes of the lung including the lower lobes.

A pneumostoma is surgically created by forming an artificial channelthrough the chest wall and joining that channel with an opening throughthe visceral membrane of the lung into parenchymal tissue of the lung toform an anastomosis. The anastomosis is joined and sealed by sealing thechannel from the pleural cavity using adhesives, mechanical sealingand/or pleurodesis.

FIG. 1B shows a sectional view of chest 100 illustrating the position ofthe pneumostoma 110. The parenchymal tissue 132 of the lung 130 iscomprised principally of alveoli 134. The alveoli 134 are the thinwalled air-filled sacs in which gas exchange takes place. Air flows intothe lungs through the natural airways including the trachea 136, carina137, and bronchi 138. Inside the lungs, the bronchi branch into amultiplicity of smaller vessels referred to as bronchioles (not shown).Typically, there are more than one million bronchioles in each lung.Each bronchiole connects a cluster of alveoli to the natural airways. Asillustrated in FIG. 1B, pneumostoma 110 comprises a channel through thethoracic wall 106 of the chest 100 between two ribs 107. Pneumostoma 110opens at an aperture 126 through the skin 114 of chest 100.

FIG. 1C shows a detailed sectional view of the pneumostoma 110. Asillustrated in FIG. 1C, pneumostoma 110 comprises a channel 120 throughthe thoracic wall 106 of the chest 100 between the ribs 107. The channel120 is joined to cavity 122 in the parenchymal tissue 132 of lung 130.The cavity 122 will typically conform to the shape of the deviceinserted into the pneumostoma 110. An adhesion or pleurodesis 124surrounds the channel 120 where it enters the lung 130. The thoracicwall 106 is lined with the parietal membrane 108. The surface of thelung 130 is covered with a continuous sac called the visceral membrane138. The parietal membrane 108 and visceral membrane 138 are oftenreferred to collectively as the pleural membranes. Between the parietalmembrane 108 and visceral membrane 138 is the pleural cavity (pleuralspace) 140. The pleural cavity usually only contains a thin film offluid that serves as a lubricant between the lungs and the chest wall.In pleurodesis 124 the pleural membranes are fused and/or adhered to oneanother eliminating the space between the pleural membranes in thatregion.

An important feature of the pneumostoma is the seal or adhesion 124surrounding the channel 120 where it enters the lung 130 which may beformed by pleurodesis. Pleurodesis creates a fusion or adhesion 124 ofthe parietal membrane 108 and visceral membrane 138. A pleurodesis maybe a complete pleurodesis in which the entire pleural cavity 140 isremoved by fusion of the visceral membrane 138 with the parietalmembrane 108 over the entire surface of the lung 130. However, as shownin FIG. 1C, the adhesion 124 is preferably localized to the regionsurrounding the channel 120. The adhesion 124 surrounding the channel120 prevents air from entering the pleural cavity 140. If air ispermitted to enter pleural cavity 140, a pneumothorax will result andthe lung may collapse.

Adhesion 124 can be created between the visceral pleura of the lung andthe inner wall of the thoracic cavity using chemical methods includingintroducing into the pleural space irritants such as antibiotics (e.g.Doxycycline or Quinacrine), antibiotics (e.g. iodopovidone or silvernitrate), anticancer therapeutic agents (e.g. Bleomycin, Mitoxantrone orCisplatin), cytokines (e.g. interferon alpha-2β and Transforming growthfactor-β); pyrogens (e.g. Corynebacterium parvum, Staphylococcus aureussuperantigen or OK432); connective tissue proteins (e.g. fibrin orcollagen) and minerals (e.g. talc slurry). Pleurodesis can also beperformed using surgical methods including pleurectomy. For example, thepleural space may be mechanically abraded during thoracoscopy orthoracotomy. This procedure is called dry abrasion pleurodesis. Apleurodesis may also be formed using radiotherapy methods, includingradioactive gold or external radiation. These methods cause aninflammatory response and or fibrosis, healing, and fusion of thepleural membranes. Alternatively, a seal can be created in an acutemanner between the pleural membranes using biocompatible glues, meshesor mechanical means such as clamps, staples, clips and/or sutures. Theadhesive or mechanical seal may develop cause pleurodesis over time. Arange of biocompatible glues are available that may be used on the lung,including light-activatable glues, fibrin glues, cyanoacrylates and twopart polymerizing glues.

When formed, pneumostoma 110 provides an extra pathway for exhaled airto exit the lung 130 reducing residual volume and intra-thoracicpressure without the air passing through the major natural airways suchas the bronchi 138 and trachea 136. Collateral ventilation isparticularly prevalent in an emphysemous lung because of thedeterioration of lung tissue caused by COPD. Collateral ventilation isthe term given to leakage of air through the connective tissue betweenthe alveoli 134. Collateral ventilation may include leakage of airthrough pathways that include the interalveolar pores of Kohn,bronchiole-alveolar communications of Lambert, and interbronchiolarpathways of Martin. This air typically becomes trapped in the lung andcontributes to hyperinflation. In lungs that have been damaged by COPDand emphysema, the resistance to flow in collateral channels (not shown)of the parenchymal tissue 132 is reduced allowing collateral ventilationto increase. Air from alveoli 134 of parenchymal tissue 132 that passesinto collateral pathways of lung 130 is collected in cavity 122 ofpneumostoma 110. Pneumostoma 110 thus makes use of collateralventilation to collect air in cavity 122 and vent the air outside thebody via channel 120 reducing residual volume and intra-thoracicpressure and bypassing the natural airways which have been impaired byCOPD and emphysema. Cavity 122 will typically conform/adapt to the sizeand shape of the device inserted into the pneumostoma.

By providing this ventilation bypass, the pneumostoma allows stale airtrapped in the parenchymal tissue 132 to escape from the lung 130. Thisreduces the residual volume and intra-thoracic pressure. The lowerintra-thoracic pressure reduces the dynamic collapse of airways duringexhalation. By allowing the airways to remain patent during exhalation,labored breathing (dyspnea) and residual volume (hyperinflation) areboth reduced. Pneumostoma 110 not only provides an extra pathway thatallows air to exit the lung 130 but also allows more fresh air to bedrawn in through the natural airways. This increases the effectivenessof all of the tissues of the lung 130 and improves gas exchange.Pneumostoma 110 thus achieves many of the advantages sought by lungvolume reduction surgery without surgically removing a portion of thelung or sealing off a portion of the lung.

Methods and instruments for forming the channel, opening, anastomosisand pleurodesis are disclosed in applicant's pending and issued patentsand applications including those related cases incorporated by referenceabove.

Pneumostoma Management Device

As described above, a pneumostoma may be created to treat the symptomsof chronic obstructive pulmonary disease. A patient is typicallyprovided with a pneumostoma management system to protect the pneumostomaand keeps the pneumostoma open on a day-to-day basis. In general terms apneumostoma management device (“PMD”) comprises a tube which is insertedinto the pneumostoma and an external component which is secured to theskin of the patient to keep the tube in place. Gases escape from thelung through the tube and are vented external to the patient. Thepneumostoma management device may, in some, but not all cases, include afilter which only permits gases to enter or exit the tube. Thepneumostoma management device may, in some, but not all cases, include aone-way valve which allows gases to exit the lung but not enter the lungthrough the tube. FIGS. 1D, 1E and 1F show an example of pneumostomamanagement device (“PMD”) 150. FIG. 1D shows a perspective view of PMD150. FIG. 1E shows a view of the chest of a patient showing PMD 150positioned in pneumostomas. FIG. 1F shows a sectional view of PMD 150positioned within pneumostoma 110.

Referring to FIG. 1D, PMD 150 includes a vent tube 152, a flange 154 anda filter 156. Filter 156 prevents liquid and solid discharge fromleaking out of the PMD and such discharge is trapped inside thepneumostoma or vent tube until the PMD is removed and replaced. Filter156 also prevents the entry of contaminants into the pneumostoma. Filter156 is preferably a hydrophobic filter to prevent leakage of fluids intoor out of the pneumostoma. Flange 154 has an adhesive coating 162 (notshown) on the distal side. The adhesive coating 162 temporarily securesflange 154 to the skin 114 of the patient. Flange 154 also prevents overinsertion of vent tube 152 by providing a mechanical stop to furtherinsertion.

As shown in FIGS. 1E and IF, during use, the vent tube 152 of PMD 150 ispushed into the pneumostoma 1 10. The vent tube is configured to fitinto a pneumostoma to keep the pneumostoma open. Gases from the lungenter an opening 158 in the distal end of vent tube 152. Vent tube 152is sized so as to pass through the thoracic wall into a portion of thepneumostoma 110 within the lung 130 as shown in FIG. 1F. However, venttube 152 but is not so long that it causes damage to the parenchymaltissue 132 of the lung 130. Vent tube 152 is preferably rounded over toprovide an atraumatic tip 166 at the distal end. A patient is providedwith a PMD having a vent tube 152 of the appropriate length for theirpneumostoma. When the patient exhales, the pressure inside the chest isabove atmospheric pressure and gases are consequently pushed through thecentral lumen of vent tube 152 and out through filter 156. Additionaldetails and variations of pneumostoma management devices are describedin applicant's pending and issued patents and applications includingthose related cases incorporated by reference above.

Pneumostoma Follow-Up Care

The patient is typically responsible for day-to-day management of thepneumostoma including replacement of the PMD and whatever daily cleaningand skin care may be required. In preferred embodiments, the PMD is adisposable unit which is changed on a daily basis or as needed. Whilechanging the PMD, the patient and/or caregiver can clean the skinsurrounding the pneumostoma and observe the condition of thepneumostoma.

A patient with a pneumostoma is also under the care of a physician andundergoes periodic checkups to monitor the condition of their lungs andof the pneumostoma. Moreover, the patient is advised to visit thephysician if certain conditions are observed. The patient thereforevisits the physician for regular follow-up visits and as indicated byobserved conditions. The patient will also preferably be enrolled in apulmonary rehabilitation program which will include: medical evaluationand management including monitoring patient compliance with pneumostomacare procedures; setting short term and long-term exercise goals;therapy programs (including smoking cessation if necessary); evaluation;and exercise. The rehabilitation program can also monitor thepneumostoma and refer the patient for assessment and treatment of thepneumostoma where indicated.

The present invention provides a number of methods and devices forpneumostoma assessment and treatment. Such assessment and treatment istypically carried by a medical professional, for example a physician,nurse, respiratory therapist and/or medical assistant (this patent willuse the term physician to include other medical care providers). FIG. 2Ashows general assessment steps that may be performed when a patientvisits a physician. The physician will typically assess the lungfunction of the patient (step 200). The physician will also assess eachpneumostoma of the patient. The assessment of the pneumostoma mayinclude one or more of an external visual inspection of the pneumostoma(step 202), an internal visual inspection of the pneumostoma (step 204);physical measurement of the pneumostoma (step 206), and a functionalassessment of the pneumostoma (step 208). The results of the assessmentsmay be compared with standard results and with prior assessments of thepatient (step 210) to determine trends and variations in thelung/pneumostoma function. Based on the assessment of the lung functionand pneumostoma, the physician determines whether any follow-upassessments and/or treatments are required (step 212).

The assessment of lung function (step 200) is performed as is typicallydone for COPD and emphysema patients. Such assessment may utilize one ormore of: patient questionnaire/self reporting, spirometry(pre-/post-bronchodilator), pulmonary function test (lung volumes),diffusion capacity (DLLO), and arterial blood gas measurement.

In the external visual inspection (step 202) the physician examines theopening to the pneumostoma and the skin of the chest surrounding thepneumostoma. The physician observes any irritation, inflammation orinfection and remediates where necessary. In the internal visualinspection (step 204) the physician examines the inside of thepneumostoma. The physician may use a pneumostoma inspection instrument.The pneumostoma inspection instrument includes a short inspection tubethat may be pushed into the pneumostoma and that provides illuminationand magnification for observation of the interior of the pneumostoma.The observation may be achieved using a direct optical train or a videodevice which displays images on a video display. The pneumostomainspection instrument is typically provided with a range of inspectiontubes of different diameters and lengths. The physician chooses theinspection tube appropriate to the dimensions of the pneumostoma of thepatient and is careful not to damage tissue of the pneumostoma duringinsertion. During the internal visual inspection the physician observesany irritation, inflammation or infection and remediates wherenecessary. The physician also makes a qualitative assessment of tissuessurrounding the pneumostoma to determine encroachment to thepneumostoma. The physician may also use the pneumostoma inspectioninstrument to measure the diameter and length of the pneumostoma and theshape and/or profile of the pneumostoma. (step 206). These may be usedto determine the size of any pneumostoma management device prescribed tothe patient and the size of any instruments to be used during treatmentof the pneumostoma. This step also allows the physician to monitor anytissue encroachment into the pneumostoma as indicated by change indimensions of the pneumostoma over time.

In the functional assessment of the pneumostoma (step 208) the physicianexamines the ability of gas to pass through the pneumostoma. The abilityof gas to pass through the pneumostoma may be measured in a number ofways. First, gas flow through the pneumostoma can be measured passivelyby placing a device over the pneumostoma which measures airflow out ofand/or into the pneumostoma during regular breathing of the patient.Alternatively, gas may be provided to the pneumostoma at a slightpositive pressure from outside the chest of the patient and the rate offlow of gas into the lung through the pneumostoma may be measured.Alternatively, as discussed below, diagnostic gases may be introducedthrough the pneumostoma to assess the patency and functionality of thepneumostoma. The diagnostic gases may be used for imaging the lungsand/or measuring collateral ventilation and gas exchange. The physicianmay compare the results of the visual, functional and/or structuralassessment with prior assessment results and standard assessment resultsto determine changes and or trends in the results (step 210).

Based upon the results of the visual, functional and/or structuralassessment of the pneumostoma and any trends in such results, thephysician may decide to treat the pneumostoma and/or surrounding tissuesto maintain or enhance the pneumostoma (step 212). The physician willselect from the available treatment modalities a treatment suitable tomaintain and/or enhance the function of the pneumostoma in light of theassessment results. (see step 220 of FIG. 2B). One or more treatmentmodalities may be used.

FIG. 2B illustrates a general method for treatment of a pneumostoma.First, based on the assessment results, the physician selects atreatment modality to maintain or enhance the health and/orfunctionality of the pneumostoma (step 220). For example, suction may beused to aspirate discharge or other materials from the pneumostoma.Irrigation/lavage may be used to introduce a liquid into the pneumostomain order to treat the tissue or aid in the removal of material from thepneumostoma. Irrigation/lavage may be used in conjunction withsuction/aspiration to remove the liquid. Suction and/or irrigation mayalso be used in conjunction with a mechanical cleaning mechanism such assoft bristles, mechanical agitation, sonic/ultrasonic agitation or thelike. The pneumostoma may be mechanically expanded using a balloondilator, mechanical dilator or other tools. The pneumostoma mayadditionally be treated with heat, cold, light, electromagneticradiation, electrocautery, sound/ultrasound, and the like.

The physician next selects a pneumostoma treatment instrument suitableto apply the treatment modality to the pneumostoma (step 222). Theselected instrument is preferably sized such that it can be introducedinto the pneumostoma and placed at a desired depth in the pneumostoma.As pneumostomas may vary in size, the instrument may have a configurablesize, or may have a range of different adapters. Thus selection of theinstrument will include selecting an instrument appropriate for thetreatment modality and selecting/configuring the instrument for thepneumostoma of a particular patient.

The selected/configured instrument is introduced into the pneumostoma(step 224). In most cases, the pneumostoma management device will needto be removed (step 223) prior to inserting the treatment device. Insome cases, the treatment modality requires contact of a target tissuewith a treatment surface of the device (step 226). In other cases, theinstrument treats the entire pneumostoma. The treatment is applied for aselected time (step 228). The effect of the treatment may then beassessed (step 230). In some cases the effect of the treatment isassessed with the pneumostoma treatment instrument. In other cases thepneumostoma treatment instrument may be removed and replaced with apneumostoma inspection instrument to permit the assessment. Thetreatment may then be repeated if and as necessary for the pneumostomaor additional targets within the pneumostoma (step 232) until thedesired effects have been achieved. After the treatment is over a newpneumostoma management device should be promptly and correctlypositioned in the pneumostoma either by the physician, or by the patientunder the observation of the physician (step 234). Particularinstruments suitable for assessing and treating pneumostomas inaccordance with the general method steps of FIG. 2A and 2B are describedbelow.

Pneumostoma Assessment Instruments And Methods

To observe the interior of the pneumostoma the physician uses apneumostoma inspection instrument placed within the pneumostoma. Onetype of pneumostoma inspection instrument includes a light source forilluminating the interior of the pneumostoma and a visualization systemfor visualizing (and typically magnifying) the interior of thepneumostoma. The visualization system may be a direct optical systemcomprising one or more optical components for providing a magnifiedimage at an object lens mounted to the instrument. Alternatively, thevisualization system may include means for obtaining a video image ofthe pneumostoma tissues and means for displaying the image, for examplea video sensor and a video display. Such a pneumostoma inspectioninstrument, using a light source and visualization system, is referredto generally herein as a pneumoscope.

A pneumoscope may include a short inspection tube or speculum that maybe pushed into the pneumostoma. The speculum holds open the pneumostomaduring the inspection. The speculum may in some cases be a detachablemetal speculum which may be sterilized between uses. Preferably,however, the speculum is disposable or covered with a disposable sleeveduring use. The speculum may be provided in a range of differentdiameters and lengths as appropriate for a particular pneumostoma orpatient. The physician chooses the speculum appropriate to thedimensions of the pneumostoma of the patient. The speculum may beprovided with visible exterior markings so that the physician may gaugethe depth of insertion of the speculum. The speculum may be providedwith a flange which prevents over-insertion of the speculum—however thedepth of insertion is typically under the control of the physician whoshould use care not to damage tissue of the pneumostoma duringinsertion. The physician may use the speculum to gauge the diameter,length and profile of the pneumostoma.

FIGS. 3A and 3B show an example of a pneumoscope according to oneembodiment of the present invention. FIG. 3A shows an external view of apneumoscope 300. FIG. 3B shows a sectional view of the pneumoscopepositioned within a pneumostoma. As shown in FIG. 3A, pneumoscope 300comprises a handle 310 and a head 320. A button 312 may be provided onhandle 310 by which a physician may activate the light source and/or anyimage capturing system. A disposable speculum 330 is attached to head320. Speculum 330 comprises a catch 332 at the proximal end fortemporarily mounting speculum 330 to head 320 of pneumoscope 300.Speculum 330 is long enough to reach the end of a pneumostoma. As shownin FIG. 3A, speculum 330 bears external markings 334 indicating how farthe distal tip 336 has travelled into the pneumostoma. External markings334 may also be used to measure the depth of a pneumostoma. Pneumoscope300 is preferably wireless and portable for ease of use.

As shown in FIG. 3B, handle 310 includes a light source 314 and powersupply 316. In use, the distal tip 336 of speculum 330 is inserted intothe pneumostoma 1 10. The physician actuates light source 314 toilluminate the interior of the pneumostoma 1 10. Light is directed fromlight source 314 to the pneumostoma 110 using an optical train 324including e.g. fiber optics and/or lenses. The optical train 324preferably provides uniform illumination of the field of view. In theembodiment of FIG. 3A, the head 320 comprises optics for viewing andmagnifying the interior of the pneumostoma 1 10. The interior of thepneumostoma 110 may be observed by the physician through objective lens322 within head 320. As shown in FIG. 3B, speculum 330 may be open atthe distal tip 336. In alternative embodiments, distal tip 336 may beclosed so long as a transparent window is provided through which thephysician may observe the interior of the pneumostoma.

FIG. 3C shows an alternative embodiment of a pneumoscope 302 comprisinga handle 340 and a head 350. One or more buttons 342 may be provided onhandle 340 by which a physician may activate the light source 370 and/orany image capturing system. A disposable cover 360 is attached to head350. Cover 360 comprises a catch 362 at the proximal end for temporarilymounting cover 360 to head 350 of pneumoscope 302. Cover 360 protects anextension 352 of head 350. Extension 352 and cover 360 are long enoughto reach the end of a pneumostoma. Cover 360 may be provided withexternal markings (not shown) indicating how far the distal tip 354 hastravelled into a pneumostoma. Pneumoscope 302 is attached to a remotelight source 370 and remote display system 378. Remote display system378 may include an image capturing system to record video images of thepneumostoma.

Light source 370 provides light which is transmitted by a fiber opticcable 372 to the distal tip 354 of extension 352. A window 356 emitslight to illuminate the field of view. A window 358 at the distal tip354 admits light which is focused on an image sensor (not shown) whichmay be e.g. a CCD or CMOS sensor. The image sensor captures video imagedata which is transmitted to the display 378. The surgeon may observevideo images of the interior of the pneumostoma on display 378 and/ormay record images of the pneumostoma for later analysis. In alternativeembodiments, one or both of the light source and display may be builtinto the head 350 and/or handle 340. Pneumoscope 302 may be insertedinto a pneumostoma in the same manner as described with respect topneumoscope 300 and illustrated in FIG. 3B.

FIG. 3D illustrates a general method for examining a pneumostoma with apneumoscope. First, based on, for example, information from the patientor observation of the pneumostoma, the physician makes a determinationto observe the pneumostoma using a pneumoscope (step 380). The physiciannext selects and/or configures a pneumoscope suitable to observe thepneumostoma of a particular patient (step 382). The selected instrumentis preferably sized such that it can be introduced into the pneumostomaand placed at a desired depth in the pneumostoma. As pneumostomas mayvary in size, the pneumoscope may have a configurable size, or may havea range of different sized speculums 330 and/or covers 360. Thusselection of the pneumoscope includes selecting/configuring thepneumoscope for the pneumostoma of a particular patient.

After the pneumoscope is ready, the pneumostoma management device willbe removed from the pneumostoma (step 383). The pneumostoma should thenbe externally inspected (step 384) to determine whether there are anycontraindications to use of a pneumoscope, for example any obstructionof the pneumostoma which must first be removed. If the externalinspection reveals no contraindications, the pneumoscope is introducedinto the pneumostoma (step 386). The physician should observe tissue ofthe pneumostoma through the visualization system of the pneumoscope(388) and note and/or record the appearance of the tissue. The physicianthen advances the pneumoscope into the pneumostoma (step 390) andrepeats the observation (step 388) until reaching the end of thepneumostoma. When the inspection is completed the pneumoscope is removed(step 392). A PMD should be inserted into the pneumostoma promptly afterremoval of the pneumoscope either by the physician, or by the patientunder the observation of the physician (step 394). In some cases,inspection with the pneumoscope is made in conjunction with treatment ofthe pneumostoma. In such a case, the pneumoscope may be used before,after and or during the treatment to observe effects of the treatmentupon the tissue of the pneumostoma.

The pneumoscope allows the physician to visually inspect and examine thetissues of the pneumostoma. The physician may observe the pneumostomaand examine the tissue in the region of the chest wall, pleurodesis,and/or within the parenchymal tissue of the lung. In the event thatinflamed, injured or unusual tissues are observed, it may be desirableto further assess the tissue. Further assessment of the tissue may bemade, for example, by swabbing the tissue and culturing anymicroorganisms on the swab. Alternatively, a biopsy of tissue of thepneumostoma may be made by scraping tissue from the walls of thepneumostoma and examining cells under the microscope. In someembodiments, the pneumoscope may be provided with an auxiliary lumenthrough which a tool may be introduced into the pneumostoma in order toscrape or swab tissue under visualization.

Pneumostoma Assessment Using Gas

Measurement of gases entering or leaving the pneumostoma may be usefulfor assessing the functionality of the pneumostoma. The ability of gasto pass through the pneumostoma may be measured in a number of ways.First, gas flow through the pneumostoma can be measured passively byplacing a device over the pneumostoma which measures airflow out ofand/or into the pneumostoma during regular breathing of the patient.Essentially, gases exiting the pneumostoma are collected by a systemwhich records the volume of gas.

Additionally, the gas may be analyzed to determine composition of thegases exiting the pneumostoma. In particular it may be useful to analyzethe proportion of oxygen, carbon dioxide and carbon monoxide in thegases exiting the pneumostoma as compared to in air exhaled through thenatural airways or in the ambient atmosphere. Levels of carbon dioxidein gases exiting the pneumostoma are a useful indicator that thepneumostoma is still functioning to allow gases to exit the lung. It mayalso be useful to measure the presence of nitric oxide in the gasesexiting the pneumostoma because nitric oxide may be indicative ofinflammation of the tissues of the lung.

Gases exiting the pneumostoma may be measured and/or analyzed with apneumostoma management device in place. However it is preferable toavoid any confounding effects due to the PMD, for example obstruction ofthe pneumostoma by the PMD, the filter of the PMD or accumulateddischarge in the PMD. Therefore gas measurement/analysis is preferablyperformed using a gas analysis device inserted into the pneumostomawhich is designed to collect gases and interface with the gasmeasurement/analysis equipment. See, e.g. FIGS. 4D and 4E. Gas analysisand measurement may be performed in a number of modes depending upon theresults desired. Different systems may be used for analysis ofpneumostoma function, lung function or lung imaging as required.

Systems for supplying gases, to a patient and analyzing gases receivedfrom a patient are already in use for supplying gases to be inhaledthrough the natural airways and analyzing gases exhaled through thenatural airways. For example a system for analyzing expiratory gases isdescribed in U.S. Pat. No. 6,506,608 titled “Method And Apparatus ForRespiratory Gas Analysis Employing Enhanced Measurement Of Expired GasMass” to Mault. A system for supplying and analyzing diagnostic gases isdescribed in U.S. Pat. No. 5,022,406 title “Module For DeterminingDiffusing Capacity Of The Lungs For Carbon Monoxide And Method” toTomlinson et al. A review of DLCO spirometry can be found in Macintyreet al., “Standardisation Of The Single-Breath Determination Of CarbonMonoxide Uptake In The Lung,” Eur. Respir. J. 26 (4): 720-35 (2005) andreference cited therein. A system for supplying and imaginghyperpolarized noble gases in the lungs is described in U.S. PatentPublication 2005/0174114 title “Method And System For Rapid MagneticResonance Imaging Of Gases With Reduced Diffusion-Induced Signal Loss”to Mugler III et al. A review of diffusion imaging of the lung can befound in Mayo et al., “Hyperpolarized Helium 3 Diffusion Imaging Of TheLung,” Radiology 222:8-11 (2202) and reference cited therein. The abovearticles, patents and applications are incorporated herein by reference.These and other such systems may be adapted as described herein tosupply and analyze gases utilizing the pneumostoma and thereby provideinformation regarding lung function, pneumostoma function and collateralventilation not previously available.

FIG. 4A shows a system for measuring/analyzing gases leaving thepneumostoma. Gas analysis equipment may be connected to a PMD and/orpneumostoma using one of the several techniques and mechanisms describedherein. As shown in FIG. 4A, a gas analysis device 400 is inserted intothe pneumostoma 110 of a patient. Gas analysis device 400 is connectedby tube 402 to gas analyzer 412. The gases exhaled from the pneumostoma110 may then be measured and/or analyzed during normal breathing orduring an exercise test. The volume of gas exhaled may be measured bygas analyzer 412 to provide information regarding thepatency/functionality of the pneumostoma. The exhaled gas may be also beanalyzed by gas analyzer 412 to determine oxygen and carbon dioxideconcentrations. In some cases, the concentrations are compared to oxygenand carbon dioxide concentrations in the gases exhaled through thenatural airways or in the ambient atmosphere. Such evaluation may beuseful in determining the effectiveness of a pneumostoma and thelocation and/or desirability of additional pneumostomas. The output ofgas analyzer 412 may be provided to a computer system 414 to display theresults of the gas analysis. Computer system 414 preferably records theresults of the gas measurement and analysis and allows the physician tocompare the results of the gas measurement/analysis with prior resultsfor the same patient.

Optionally, a mask 416 may be provided. Mask 416 may be used to measurethe volume of gas inhaled and exhaled by the patient through the naturalairways. The volume of gas inhaled and exhaled through the naturalairways may be compared to the volume of gas exiting the pneumostoma.Optionally, a diagnostic gas 418 is introduced through the naturalairways and the expiration of gases from the pneumostoma is measured.Computer system 414 controls valve 406 to supply the diagnostic gas 418to the mask 416. The diagnostic gas may, for example, be a gas mixturesuch as DLCO gas used in diffusion spirometry (which nominally consistsof 10% helium, 3000 ppm carbon monoxide and the balance air). As shownin FIG. 4A, optional mask 416 may be used to provide a diagnostic gasmixture 418 via the natural airways. The concentration of gases exitingthe pneumostoma 110 may be compared to the concentration of gases in thediagnostic gas supply 418. The time-course of exhalation of diagnosticgases through the pneumostoma may be analyzed by gas analyzer 412 toevaluate the function of the pneumostoma and the prevalence ofcollateral ventilation pathways connecting the pneumostoma to theremainder of the lung. Such evaluation may be useful in determining theeffectiveness of a pneumostoma and the location and/or desirability ofadditional pneumostomas.

Alternatively, gases may be provided through the pneumostoma fromoutside the chest of the patient. Gas supply equipment may be connectedto a PMD and/or pneumostoma using one of the several techniques andmechanisms described herein. The gas is preferably supplied at acontrolled pressure slightly above the ambient air pressure so as not tocause injury to the pneumostoma. In a simple case, the rate of flow ofgas into the lung through the pneumostoma may be measured. The rate ofgas flow at a particular pressure may be used to assess the patency ofthe pneumostoma. Alternatively, diagnostic gases may be introducedthrough the pneumostoma for assessing collateral ventilation and gasexchange. Diagnostic gases may be helpful in measuring functionalattributes of the pneumostoma and the lung. In particular, introductionof diagnostic gases through the pneumostoma may be useful for assessinggas diffusion between the pneumostoma and the lung.

In one example, a diagnostic gas is introduced through the pneumostomaand the gas is measured as it is exhaled through the natural airways.The diagnostic gas may, for example, be a gas mixture such as DLCO gasused in diffusion spirometry (which nominally consists of 10% helium,3000 ppm carbon monoxide and the balance air). Gases exhaled through thenatural airways are analyzed to determine gas concentrations. The timecourse of exhalation of the diagnostic gas is indicative of factors suchas pneumostoma functionality and collateral ventilation. The time courseof exhalation of gas through the natural airways compared tointroduction into the pneumostoma may be analyzed to evaluate thefunction of the pneumostoma and the prevalence of collateral ventilationpathways connecting the pneumostoma to the remainder of the lung. Suchevaluation may be useful in determining the effectiveness of apneumostoma and the location and/or desirability of additionalpneumostomas. A supply of the diagnostic gas may be connected to a PMDand/or pneumostoma using one of the several techniques and mechanismsdescribed herein.

FIG. 4B shows a schematic view of a lung assessment system usingintroduction of diagnostic gas 418 through a pneumostoma 110. As shownin FIG. 4B a gas analysis device 400 is inserted into the pneumostoma110 of a patient. Gas analysis device 400 is connected by tube 402 to apressure-regulated source of diagnostic gas 418. A solenoid-controlledvalve 406 in tube 402 controls the flow of diagnostic gas intopneumostoma 110. The patient is provided with a mask 416 which allowsthe patient to inhale ambient air but that collects the exhaled air andpasses it to gas analyzer 412. During exhalation, a portion of theexhaled gases is collected in a sample collection system and thenanalyzed using discrete gas sensors and/or a gas chromatograph. The gasanalyzer 412 and the solenoid-controlled valve 406 are connected to acomputer system 420 which may be a general purpose computer. Computersystem 420 controls solenoid-controlled valve 406 and receives data fromgas analyzer 412. Computer system 420 analyzes the gas concentrations inthe gas exhaled by the patient and factors the relative values withinspired gas volume and other parameters to calculate factors related tocollateral ventilation and pneumostoma function. The output of gasanalyzer 412 may be provided to computer system 420 to display theresults of the gas analysis. Computer system 420 preferably records theresults of the gas measurement and analysis and allows the physician tocompare the results of the gas measurement/analysis with prior resultsfor the same patient.

Introduction of diagnostic gases through a pneumostoma may also be usedto enhance imaging the lung with a CT scan or NMR scan. For examplepolarized Helium-3 may be utilized to enhance nuclear magneticresonance/magnetic resonance imaging of the lung (analogous to the waycontrast agents enhance X-ray imaging). For example, polarized helium-3may be produced with lasers and the magnetized pressurized gas may bestored for several days. When introduced into the lung, the polarizedhelium-3 can be imaged with an MRI-like scanner which producesbreath-by-breath images of lung ventilation, in real-time. Polarizedhelium-3 may thus, be used to visualize airways in static or dynamicfashion. Alternative gases which may be used as visualization agentsinclude gaseous radionuclide xenon or technetium DTPA in an aerosolform.

Introducing a controlled amount of a visualizable gas, e.g. polarizedHelium-3, through the pneumostoma and imaging the diffusion of the gasinto the lung over time may be utilized for quantitative evaluation ofthe function of the pneumostoma and the prevalence of collateralventilation pathways connecting the pneumostoma to the parenchymaltissue of the lung. Measuring the time-course variations in diffusion ofHelium-3 into the lung allows analysis of diffusion coefficients forareas of the lung. Such evaluation may be useful in determining theeffectiveness of a pneumostoma and the location and/or desirability ofadditional pneumostomas. A source of polarized Helium-3 may be connectedto a PMD and/or pneumostoma using one of the several techniques andmechanisms described herein.

FIG. 4C shows a schematic view of a lung assessment system using adiagnostic gas in conjunction with an imaging scanner 450. Scanner 450may be an MRI, NMR, CT or X-Ray so long as the particular diagnostic gasused may be successfully imaged with the system. As shown in FIG. 4B,gas analysis device 400 is inserted into the pneumostoma 110 of apatient. Gas analysis device 400 is connected by tube 430 to apressure-regulated source of a visualizable gas (e.g. polarizedHelium-3). A solenoid-controlled valve 432 in tube 430 controls the flowof diagnostic gas into pneumostoma 110. The scanner 450 and thesolenoid-controlled valve 432 are connected to a computer system 420(not shown) which may be a general purpose computer. The computer system420 (not shown) controls solenoid-controlled valve 432 and receives datafrom scanner 450. The computer system 420 coordinates the introductionof diagnostic gas into the patient with the patient's breathing and alsowith the operations of scanner 450 in order to accurately imagedispersion of the diagnostic gas from the pneumostoma 110 to other partsof the lung. Computer system 420 analyzes the time course distributionof the diagnostic gas from the pneumostoma into the lung tissues tocalculate factors related to collateral ventilation and pneumostomafunction, e.g. diffusion coefficients.

FIGS. 4D and 4E show views of the gas analysis device 400 of FIGS.4A-4C. FIG. 4D shows a perspective view of the gas analysis device 400while FIG. 4E shows a sectional view of gas analysis device 400positioned within a pneumostoma. In general terms, gas analysis device400 is a device which can be secured into a pneumostoma for samplinggases exiting the pneumostoma and/or providing gases into thepneumostoma. Gas analysis device 400 can form part of a system whichutilizes such gas sampling or gas provision for assessment ofpneumostoma function and/or lung function. As used in FIGS. 4A and 4C,gas analysis device 400 is used to introduce diagnostic gas into thepneumostoma. As used in FIG. 4B, gas analysis device 400 is used tocollect gases exhaled from the lung for analysis by gas analyzer 412.

Referring to FIG. 4D, gas analysis device 400 includes a hollow tube 460for insertion into the pneumostoma. Hollow tube 460 is surrounded by aflange 462 which secures tube 460 in position in the pneumostoma. Hollowtube 460 connects to a coupling 464 on the proximal side of flange 462.Coupling 464 is configured so that tube 402 (shown in FIG. 4E) may bereadily connected and disconnected. Hollow tube 460 has one or moreholes 466 at the distal end through which gas may pass into or out of apneumostoma. Hollow tube 460 and flange 462 also provide a temporaryseal which inhibits leakage of gas from around hollow tube 460.

FIG. 4E shows a sectional view of gas analysis device 400 of FIGS. 4A-4Din position in a pneumostoma 110. It is preferable to minimize leakageof gases into or out of the pneumostoma. Flange 462 is thus providedwith an adhesive coating 468 on the distal surface to provide atemporary seal between the gas analysis device 400 and the skin of thechest of the patient. Surface features may also be provided on thedistal surface of flange 462 or on tube 460 to promote sealing betweengas analysis device 400 and the pneumostoma. For example, a circularridge 470 is shown in section on FIG. 4E. Gas analysis device 400 ispreferably a disposable component that will be used only with onepatient. One or more filters may be interposed between gas analysisdevice 400 and the gas supply and/or gas analyzer to prevent possiblecross-contamination between patients.

Pneumostoma Treatment

Based upon the assessment of the pneumostoma, it may be necessary ordesirable to treat the pneumostoma in order to preserve and/or enhancethe health and/or functionality of the pneumostoma. A principal purposeof the pneumostoma is to permit the escape of gases trapped in the lungthereby reducing the lung volume and ameliorating symptoms of COPD suchas dyspnea and anoxia. To serve this purpose gases should be able toenter the pneumostoma from the parenchymal tissue of the lung. Highrates of air flow are not required. However, if the pneumostoma becomescompletely obstructed then it will no longer permit the escape of gasestrapped in the lung. The function of the pneumostoma may be impaired by,among other causes, the encroachment of tissues into the pneumostoma,obstruction with secretions, discharge and/or foreign objects,inflammation and/or infection. For example, encroaching tissues mayimpair the patency and functionality of the pneumostoma.

The pneumostoma and surrounding tissues may be treated using a number ofdifferent treatment modalities to maintain and/or enhance patency,remove obstructions, decrease inflammation and prevent infection. Thetreatment modalities include: suction, irrigation, lavage, mechanicalagitation, ultrasound, infrasound, mechanical dilation, balloondilatation, cryotherapy, and energy treatment (including e.g. UV, light,LASER, LED, IR, heat, RF and electrocautery). The physician may selectfrom among the several treatment modalities a treatment modality mostappropriate for the conditions observed during the pneumostomaassessment.

Pneumostoma Treatment Using Suction, Irrigation and Lavage

The treatment modalities available for treating a pneumostoma includesuction, irrigation, mechanical agitation and lavage. These treatmentmodalities are suitable for removing obstructions and discharge from thepneumostoma, cleaning the pneumostoma and treating the tissues of thepneumostoma. Additional methods and devices for applying suction to apneumostoma are disclosed in applicant's U.S. Provisional PatentApplication 61/084,559 titled “Aspirator For Pneumostoma Management”which is incorporated herein by reference. An aspirator may be usedwithout irrigation for the removal of liquid/soft discharge andmaterials from the pneumostoma.

FIGS. 5A-5C illustrate a device for treating a pneumostoma with suction,irrigation, mechanical irritation and/or lavage. As shown in FIG. 5A, asuction-irrigation device 500 includes a body 510 attached to asuction-irrigation probe 520. Suction-irrigation probe 520 includes amulti-lumen tube 522 and a flange 524. As shown in the sectional viewFIG. 5B of suction-irrigation probe 520, multi-lumen tube 522 has anouter lumen 521 and an inner lumen 523. Referring again to FIG. 5A,multi-lumen tube 522 has a number of side apertures 526 for releasingfluid from the outer lumen 521. Multi-lumen tube 522 has a distalaperture 528 in the distal tip for applying suction and removing fluidvia the inner lumen 523. Distal aperture 528 may be provided with a cageor mesh covering to prevent damage to tissues and/or obstruction ofdistal aperture 528. Multi-lumen tube 522 also supports a plurality ofsoft bristles 530 for mechanically agitating the surface of apneumostoma. Although bristles are shown, other mechanical features maybe used to assist the removal of material which may be adhered to thetissue of the pneumostoma, for example ribs, fingers or surfaceroughness.

Referring now to FIG. 5C, suction irrigation probe 520 is connected to abody 510 by a coupling 532 which mounts releasably to a mating coupling512 on body 510. Body 510 is also connected to a pressure-regulatedsupply of irrigation fluid and a pressure-regulated vacuum supply (notshown). The irrigation supply and vacuum supply are attached orconnected to an irrigation conduit 514 and suction conduit 516 withinbody 510. The couplings 532 and 512 releasably mount thesuction-irrigation probe 520 to body 510. The couplings 532 and 512 alsoput the lumens of multi-lumen tube 522 in fluid communication with theirrigation conduit 514 and suction conduit 516 within body 510. Thereleasable couplings 532 and 512 also enable the suction-irrigationprobe 520 to be removed, and either cleaned and replaced, or disposed ofand replaced. Couplings 532, 512 may be, for example, threadedcouplings, bayonet couplings, luer locks or other connector suitable forreleasable connecting lumens.

FIG. 5C shows a sectional view of suction-irrigation device 500 withsuction-irrigation probe 520 inserted into a pneumostoma 110. As shownin FIG. 5C, irrigation fluid exits through side apertures 526 and iscollected through distal aperture 528. Bristles 530 contact the tissueof the pneumostoma 110. Suction-irrigation probe 520 may be moved in andout of pneumostoma 110 so that bristles 530 dislodge any material stuckon the side of pneumostoma 110. The irrigation fluid serves to move anydislodged materials into aperture 528. Flange 524 serves to preventover-insertion of suction-irrigation probe 520 and also to preventexcessive leakage of irrigation fluid from the pneumostoma. In someembodiments, flange 524 may be configured to slide up and downmulti-lumen tube 522 such that the depth of the distal end of probe 520may be adjusted while the flange remains in contact with the chest ofthe patient. In other embodiments, flange 524 may be fixed or adjustablyfixed to multi-lumen tube 522.

Suction-irrigation device 500 may include additional features tofacilitate removal of material from the pneumostoma. For example,suction-irrigation device 500 may include a visualization system topermit the physician to guide suction-irrigation probe 520 and visualizethe tissues inside pneumostoma 110. See, e.g. FIGS. 3A-3C andaccompanying text. Suction-irrigation device 500 may also include anultrasound generator or another device to agitate bristles 530 and theirrigation fluid to aid in the mechanical removal of materials from thepneumostoma 110. Suction irrigation device 500 may also include a trapfor trapping any solid materials dislodged from the pneumostoma. Forirrigation, a sterile but inert solution may be used. For example,sterile saline or sterile water may be used. The irrigation fluid willtypically be sterile water or saline solution. In some cases, it may bedesirable to use a medicated irrigation fluid. For example, anantibacterial or mucolytic solution may be used. In such cases a smallconcentration of the therapeutic agent is added to the sterile water orsaline. Suitable therapeutic agents include anti-inflammatories,antibiotics and anti-stenosis compounds. The irrigation fluid may alsoinclude a small concentration of an agent for maintaining the patency ofthe pneumostoma, for example, Paclitaxel. The cleaning solution shouldbe formulated carefully to avoid injury or irritation to the lung.

FIG. 5D illustrates a method for treatment of a pneumostoma. First,based on, for example, information from the patient or observation ofthe pneumostoma, the physician makes a determination to treat thepneumostoma with one or more of suction, irrigation and/or lavage. (step580). The physician next selects and/or configures anaspirator/irrigator suitable to treat the pneumostoma of a particularpatient. (step 582). The selected instrument is preferably sized suchthat it can be introduced into the pneumostoma and placed at a desireddepth in the pneumostoma. As pneumostomas may vary in size, theaspirator/irrigator may have a configurable size, or may have a range ofdifferent sized probes 520. Thus selection of the aspirator/irrigatorincludes selecting/configuring the aspirator/irrigator for thepneumostoma of a particular patient. If irrigation/lavage is to beperformed, the physician should also select and/or prepare theirrigation fluid (step 584).

After the aspirator/irrigator and optional irrigation fluid is ready,the pneumostoma management device will be removed from the pneumostoma(step 586). The pneumostoma should then be externally inspected (step588) to determine whether there are any contraindications to use of theaspirator/irrigator, for example any obstruction of the pneumostomawhich must first be removed. If the visual inspection reveals nocontraindications, the aspirator/irrigator is introduced into thepneumostoma (step 590). The physician may then position the flange so asto prevent excess leakage from the pneumostoma (step 592). The physicianwill the apply suction to remove materials from the pneumostoma (step594). While suction is applied the physician may also provideirrigation/lavage and or agitation to dislodge materials for removal(step 594.) The physician may advance the aspirator/irrigatorincrementally further into the pneumostoma and repeats the treatment(step 594) until reaching the end of the pneumostoma. When the treatmentis completed the aspirator/irrigator is removed (step 596). A PMD shouldbe inserted into the pneumostoma promptly after removal of theaspirator/irrigator either by the physician, or by the patient under theobservation of the physician (step 598). In some cases, treatment withthe aspirator/irrigator is made in conjunction with inspection of thepneumostoma with a pneumoscope. In such case, the pneumoscope may beused before and after treatment to observe effects of the treatment uponthe tissue of the pneumostoma and to ensure all deleterious materialshave been removed from the pneumostoma.

Pneumostoma Treatment Using Sound

The treatment modalities available for treating a pneumostoma includethe use of sound waves. Sound waves can be used to agitate the walls ofthe pneumostoma to dislodge materials. Sound waves of differentfrequencies may be of use, including infrasound below 20 Hz, acousticsound waves between 20 Hz and 20 KHz and ultrasound above 20 KHz. Thesetreatment modalities are suitable for removing obstructions anddischarge from the pneumostoma, cleaning the pneumostoma and treatingthe tissues of the pneumostoma to enhance and/or maintain patency of thepneumostoma. The amplitude, frequency and duration of sound wavessupplied may be selected to achieve the desired effects. In some casesthe amplitude, frequency and duration of the sound waves may besufficient to kill cells, inhibit proliferation of cells or disruptcells and connective tissue in order to enhance or maintain the patencyof the pneumostoma. In other cases, the sound waves may be selected todislodge materials e.g. discharge, which may be adhered to the tissuesof the pneumostoma. In some embodiments, ultrasound may be used inconjunction with suction/irrigation to remove materials from thepneumostoma.

FIG. 6A shows a sectional view of an ultrasound device 600 for use in apneumostoma 110. Ultrasound device 600 includes a body 610 containing anultrasonic transducer 612 coupled by a coupling 614 to an ultrasoundprobe 620. Ultrasonic transducer 612 is coupled to ultrasound probe 620so that, when energized, ultrasonic transducer 612 transmits ultrasoundinto ultrasound probe 620. Ultrasound device 600 includes within body610, a switch 617, a controller 616 and power supply 618. The physicianoperates switch 617 to cause controller 616 to energize ultrasonictransducer 612. In preferred embodiments, controller 616 energizesultrasonic transducer 612 for a predefined and limited period of time.

Ultrasound probe 620 is sized and configured to enter pneumostoma 110and conduct ultrasound energy from ultrasonic transducer 612 to thewalls of the pneumostoma and any materials adhered thereto. Ultrasoundprobe 620 may also include a flange 622 which serves as protectionagainst over insertion of probe 620. A biocompatible gel or liquid (notshown) may be used with ultrasound probe 620 to enhance the conductionof ultrasonic waves from ultrasound probe 620 to tissues of thepneumostoma. In such case, flange 622 may also be useful to create atemporary seal to retain the gel or liquid with pneumostoma 110 duringthe ultrasound treatment. In some embodiments, ultrasound probe 620 maybe provided with a channel to provide suction to remove any materialsdislodged by the ultrasound. Alternatively, a separatesuction/irrigation device may be utilized to remove materials from thepneumostoma after treatment with the ultrasound probe 620.

FIG. 6B shows a schematic view of alternate sound delivery device 650for use in a pneumostoma 110. Sound delivery device 650 includes a body660 containing a speaker 662 which typically comprises amagnetically-driven armature or diaphragm. Speaker 662 generatesacoustic and/or infrasound waves in chamber 664. Chamber 664 is incommunication via coupling 668 with sound probe 670. As shown in FIG.6B, sound probe 670 is a hollow tube for holding open the pneumostomaand delivering the sound waves into the pneumostoma. Sound probe 670 mayhave one or more apertures. A baffle may be provided around sound probe670 to concentrate pressure waves induced by the speaker with thepneumostoma. Alternatively, sound probe 670 may be a solid probe coupledto the armature of speaker 662 or a suitable transducer. In alternativeembodiments, the sound may be generated by a speaker located within theprobe which is thus located within the pneumostoma during use. Theenergy delivered by sound delivery device 650 serves to dislodgematerials from the pneumostoma and/or disrupt the connective tissue ofthe pneumostoma. In some embodiments, sound probe 670 may be providedwith a channel to provide suction to remove any materials dislodged bythe sound waves. Alternatively, a separate suction/irrigation device maybe utilized to remove materials from the pneumostoma after treatmentwith the sound delivery device 650.

FIG. 6C illustrates a method for treatment of a pneumostoma. First,based on, for example, information from the patient or observation ofthe pneumostoma, the physician makes a determination to treat thepneumostoma with one or more of acoustic sound, infrasound, and/orultrasound. (step 680). The physician next selects and/or configures asound/ultrasound device suitable to treat the pneumostoma of aparticular patient. (step 682). The selected instrument is preferablysized such that it can be introduced into the pneumostoma and placed ata desired depth in the pneumostoma. As pneumostomas may vary in size,the sound/ultrasound device may have a configurable size, or may have arange of different sized probes 620 or 670. Thus selection of thesound/ultrasound device includes selecting/configuring thesound/ultrasound device for the pneumostoma of a particular patient. Ifa sound conducting liquid or gel is to be used, the physician shouldalso select and/or prepare the fluid (step 684).

After the sound/ultrasound device and optional sound-conducting fluid isready, the pneumostoma management device will be removed from thepneumostoma (step 686). The pneumostoma should then be externallyinspected (step 688) to determine whether there are anycontraindications to use of the sound/ultrasound device, for example anyobstruction of the pneumostoma which must first be removed. If thevisual inspection reveals no contraindications, the sound/ultrasounddevice is introduced into the pneumostoma (step 690). The physician maythen position the flange so as to prevent excess leakage from thepneumostoma (step 692). The physician will then energize thesound/ultrasound probe for a selected period of time (step 694). Thephysician may advance the sound/ultrasound device incrementally furtherinto the pneumostoma and repeat the treatment (step 694) until reachingthe end of the pneumostoma. When the treatment is completed thesound/ultrasound device is removed (step 696). A PMD should be insertedinto the pneumostoma promptly after removal of the aspirator/irrigatoreither by the physician, or by the patient under the observation of thephysician (step 698).

In some cases, treatment with the sound/ultrasound device is made inconjunction with inspection of the pneumostoma with a pneumoscope. Insuch case, the pneumoscope may be used before and after treatment toobserve effects of the treatment upon the tissue of the pneumostoma andto ensure all deleterious materials have been removed from thepneumostoma. It may also be desirable to clean the pneumostoma withsuction/irrigation prior to reinsertion of the PMD in order to removeany materials that may have been dislodged during the treatment.

Pneumostoma Treatment Using Mechanical Dilatation

The treatment modalities available for treating a pneumostoma includethe use of mechanical dilatation. Overtime, the natural healing responseof the body may cause tissues to encroach into the lumen of thepneumostoma. Additionally, the tissues bordering the pneumostoma maythicken over time reducing the permeability of the pneumostoma walls togases. A dilator may be used to stretch the tissues of the pneumostomato maintain the patency of the pneumostoma. Dilatation not onlyincreases the size of the lumen of the pneumostoma but also thins thetissues surrounding the pneumostoma. This thinning of the tissuesbordering the pneumostoma in the lung may enhance the ability of air toenter the pneumostoma from the parenchymal tissue of the lung therebyenhancing the functionality of the pneumostoma. In embodiments, adilator comprises an expander which can be inserted into the pneumostomaat a first contracted size and then expanded to a desired expanded sizethereby stretching the pneumostoma. In preferred embodiments the dilatorcomprises an indicator outside the body which indicates the extent towhich the expander has been expanded and/or an adjustable limiter whichlimits expansion of the expander to a safe amount.

FIGS. 7A-7D show views of one embodiment of mechanical dilator 700. Asshown in FIG. 7A, mechanical dilator 700 comprises a handle 710, a shaft720 and an expander 730. Handle 710 includes two arms 712a, 712bconnected by a pivot 714. A spring mechanism 716 biases arms 712a, 712bapart. A screw mechanism 717 may be used to lock arms 712a, 712b closertogether at any desired position. A limit mechanism 715 may be used tolimit the approach of arm 712a towards arm 712b in order to prevent overexpansion of the expander 730. Handle 710 is connected to shaft 720. Arm712a, is fixedly connected to the exterior of shaft 720, arm 712 b ispivotally connected to inner shaft 722. Moving arm 712 b towards arm 712a moves inner shaft 722 more distally relative to shaft 720. Handle 710also includes a gauge 718 marked to indicate the amount of expansion ofexpander 730. Gauge 718 is fixed to arm 712 a. An indicator 719 fixed toarm 712 b moves along gauge 718 as the arms are moved towards each otherthereby expanding expander 730. The markings on gauge 718 correspond tothe expansion of expander 730.

Shaft 720 is sized so as to fit into the pneumostoma. Shaft 720 may beprovided with markings 724 on the exterior surface so the physician maydetermine the depth to which the distal tip of expander 730 has beeninserted in the pneumostoma. Expander 730 includes two blades 732 a, 732b. Blades 732 a, 732 b are semicircular in section so that, in thecollapsed configuration, blades 732 a, 732 b form a cylinder of the sameexternal diameter as shaft 720. Blades 732 a, 732 b also form a roundeddistal tip 734 in their collapsed configuration to facilitate insertionof expander 730 into the pneumostoma.

FIG. 7B shows mechanical dilator inserted into a pneumostoma 110 (shownin section). As shown in FIG. 7B, the mechanical dilator 700 is insertedinto the pneumostoma 110 in the collapsed configuration of FIG. 7A untilit is located at the desired depth in the pneumostoma as indicated bythe markings 724. In some situations, mechanical dilator 700 may be usedto measure the diameter of a pneumostoma. The expander may be insertedinto the pneumostoma and the handles compressed until resistance isfelt. The indicator 719 will indicate on gauge 718 the degree ofexpansion of expander 730 at this point of first resistance and thusindicate the internal diameter of the pneumostoma. Limit mechanism 715may then be positioned to allow only a desired amount of incrementalexpansion of the pneumostoma compared to the measured initial diameterof the pneumostoma. In alternative embodiments, a fixed or adjustableflange (not shown) may be provided mounted on shaft 720. The flangeserves as mechanical stop to limit insertion of the mechanical dilator700 at a fixed or adjustable depth.

FIG. 7C shows a close-up view of the expander 730 in an expandedconfiguration. As shown in FIG. 7C, each of blades 732 a and 732 b arepivotably connected by linkages 736 a, 736 b to the distal end of shaft720. Each of blades 732 a, 732 b is also pivotably connected to thedistal end of inner shaft 722 by linkages 738 a, 738 b, 738 c, 738 d.Linkages 738 a, 738 b, 738 c, 738 d are designed to fit within a slot inthe interior surface of blades 732 a, 732 b when the blades are in thecollapsed configuration of FIG. 7A. In alternative embodiments, expander730 may have 3 or more blades, each blade taking up a fractional portionof the circumference of the device and each blade having three linkagesconnecting the blade to the distal end of inner shaft 722. As innershaft 722 moves in the direction of arrow 704, blades 732 a, 732 b moveoutwards as shown by arrows 702 a, 702 b.

FIG. 7D shows mechanical dilator 700 positioned in a pneumostoma 110. Asshown in FIG. 7D, expander 730 is positioned within the pneumostoma atthe desired depth. Handle 712 b has been pushed towards handle 712 auntil it makes contact with limit mechanism 715. Handle 712 b mayoptionally be locked into position with screw mechanism 717. Inner shaft722 has been pushed distally relative to shaft 720. Linkages 738 a, 738,b, 738 c, 738 d have thus forced blades 732 a, 732 b away from eachother causing the expander 730 to adopt the expanded position shown inFIG. 7C (see FIGS. 7B and 7C for identification of the components ofexpander 730). Note that indicator 719 has moved along gauge 718 toindicate the amount of expansion of expander 730.

In practice, mechanical dilator 700 is preferably expanded a smallamount and then locked in place as the tissues of the pneumostoma relax.Mechanical dilator 700 is then expanded another small amount and thenlocked in place again as the tissues of the pneumostoma relax. A numberof incremental expansion steps may be performed until the desireddiameter of the pneumostoma is achieved. The incremental steps can becontrolled by incremental movement of limit mechanism 715 and screwmechanism 717. In some cases, it may be desirable to expand the dilatorat two or more different depths in the pneumostoma so as to expand twoor more different potions of the pneumostoma. Dilator 700 may then becollapsed and withdrawn from the pneumostoma. The pneumostoma will tendto contract after dilatation so it is important to insert a pneumostomamanagement device into the lumen of the pneumostoma upon removal of themechanical dilator 700.

FIG. 7E illustrates a method for treatment of a pneumostoma with adilator. First, based on, for example, information from the patient orobservation of the pneumostoma, the physician makes a determination totreat the pneumostoma with a dilator. (step 740). The physician nextselects and/or configures a dilator suitable to treat the pneumostoma ofa particular patient. (step 742). The selected instrument is preferablysized such that it can be introduced into the pneumostoma and placed ata desired depth in the pneumostoma. As pneumostomas may vary in size,the dilator may have a configurable size, or a range of initial sizes.Thus selection of the dilator includes selecting/configuring the dilatorfor the pneumostoma of a particular patient such that it may be insertedinto the pneumostoma to the desired depth prior to dilation. Afterdilation of the pneumostoma it is preferable to insert a PMD to supportthe pneumostoma as soon as the dilator is removed. Therefore, it ispreferable to select and prepare a larger PMD for the patient to fit theanticipated dilated pneumostoma (step 744).

After the dilator and replacement PMD are, the original (smaller)pneumostoma management device will be removed from the pneumostoma (step746). The pneumostoma should then be externally inspected (step 748) todetermine whether there are any contraindications to use of the dilator,for example any obstruction of the pneumostoma which must first beremoved. If the visual inspection reveals no contraindications, thedilator is introduced into the pneumostoma (step 750). The physician maythen expand the dilator incrementally (step 752). The physician willthen allow the tissue of the pneumostoma to relax (step 754) and repeatthe incremental expansion (step 752) until the desired dilation has beenachieved. The physician may also repeat the dilation at one or moredepths within the pneumostoma depending upon the length of thepneumostoma. When the dilation is complete the dilator is removed (step756). A new larger PMD should then be promptly inserted into thepneumostoma by the physician, or by the patient under the observation ofthe physician (step 758).

In some cases, treatment with the sound/ultrasound device is made inconjunction with inspection of the pneumostoma with a pneumoscope. Insuch case, the pneumoscope may be used before and after treatment toobserve effects of the treatment upon the tissue of the pneumostoma andto ensure all deleterious materials have been removed from thepneumostoma. It may also be desirable to clean the pneumostoma withsuction/irrigation prior to reinsertion of the PMD in order to removeany materials that may have been dislodged during the treatment.

Alternative means may be used to dilate the pneumostoma in alternativeembodiments. FIG. 7F shows an alternative mechanical dilator 760 andFIG. 7G shows a balloon dilator 780. Referring to FIG. 7F, mechanicaldilator 760 comprises first handle 761 connected to inner shaft 762which extends to the distal tip of the mechanical dilator 760. A secondhandle 763 is connected to an outer shaft 764 which rides on inner shaft762. At the distal end of mechanical dilator 760 is expander 766.Expander 766 includes a plurality of flexible elements 767 covered by apolymer shell 768. The distal end of each flexible element 767 andpolymer shell 768 is connected to the distal end of inner shaft 762. Theproximal end of each flexible element 767 and polymer shell 768 isconnected to the distal end of outer shaft 764. When outer shaft 764 ispushed distally along inner shaft 762 (as shown by arrow 770), flexibleelements 767 bend or bow outwards (as shown by arrows 771). Elements 767push on polymer shell 768 causing it to also bow outwards (in thedirection of arrows 771). Thus mechanical dilator 760 transitions fromthe collapsed configuration to the expanded configuration by pushinghandle 763 distally relative to handle 761. Both outer shaft 764 andinner shaft 762 have markings 765 on the exterior surface so thephysician may assess the depth of insertion of mechanical dilator 760and the diameter of expansion of mechanical dilator 760. Mechanicaldilator 760 may be used in the same way as dilator 700 of FIGS. 7A-7D,either for dilating the pneumostoma or assessing the diameter of thepneumostoma. Mechanical dilator 760 may additionally be provided with alocking device to hold it in an expanded position and/or a limit deviceto control expansion of the expander 766.

FIG. 7G shows a balloon dilator 780. Referring to FIG. 7F, mechanicaldilator 780 comprises first handle 781 connected to a hollow shaft 782which extends to the distal tip of the balloon dilator 780. At thedistal end of mechanical dilator 780 is balloon 786. Balloon 786 issealed to the hollow shaft at the proximal end 787 and distal end 788 ofballoon 786. An aperture in hollow shaft 782 communicates between thelumen of the hollow shaft 782 and the interior of balloon 786. A syringe792 is connected to the proximal end of hollow shaft 782. When syringe792 is compressed (as shown by arrow 790), a liquid such as sterilesaline is pushed through hollow shaft 782 into balloon 786 causingballoon 786 to inflate (as shown by arrows 791). Thus balloon dilator780 transitions from the collapsed configuration to the expandedconfiguration by compressing syringe 792. Hollow shaft 782 has markings785 on the exterior surface so the physician may assess the depth ofinsertion of balloon dilator 780. Syringe 792 has exterior markings 795so that the physician may assess the volume of balloon 786 and hence thediameter to which it has been expanded. Balloon dilator 780 may be usedin the same way as dilator 700 of FIGS. 7A-7D, either for dilating thepneumostoma or assessing the diameter of the pneumostoma.

Balloon 786 may be formed of a relatively inelastic material. In suchcase, injection of the liquid into the balloon will expand the balloonto a preset size. This ensures that the balloon does not stretch thepneumostoma more than desired. Moreover, the balloon can be expanded athigh pressure without risk of over-expansion. However, a number ofdifferent balloon dilators may be required having different sizes inorder to treat different pneumostomas or to incrementally expand asingle pneumostoma. In alternative embodiments, a relatively elasticmaterial may be used to make balloon 786. In such case, the balloon willhave a larger diameter for larger amounts of liquid allowing broaderapplication. However, the pressure applied by the balloon to the tissuewill be lower than for an inelastic balloon.

Pneumostoma Treatment Using Localized Thermotherapy

The treatment modalities available for treating a pneumostoma includethe application of heat (thermotherapy) or cold (cryotherapy).Thermotherapy and cryotherapy can be used to affect physicalcharacteristics of tissues and cell proliferation and also to treatinfection. For example, the tissues of the pneumostoma tend to encroachinto the lumen of the pneumostoma thereby impairing the function of thepneumostoma. One way to reduce tissue encroachment is through the use ofthermotherapy or cryotherapy thereby maintaining or enhancing thepatency of the pneumostoma. In some embodiments a pneumostoma treatmentdevice may be used to heat the tissue in others the pneumostomatreatment device may be used to cool the tissue to achieve the desiredeffects.

In one method of thermotherapy, a surface of a pneumostoma treatmentdevice is brought into contact with a target tissue of the pneumostoma.The surface of the pneumostoma treatment device is then heated to raisethe temperature of the target tissue (e.g. by electrical heating, laserheating, or by circulating a heated medium). Other methods ofthermotherapy include application of focused ultrasound, infrared light,radio or microwave-frequency radiation to the target tissue to inducethe desired temperature rise in the target tissue. For example,thermotherapy treatment device may direct energy at the tissue to heatthe target tissue. The energy may be supplied as ultrasound, electricalenergy, electromagnetic energy (for example IR or laser energy). Thetreatment is applied for a selected period of time. After the treatmentthe tissue is reassessed and treated again as necessary. The treatmentmay be applied to the pneumostoma tissue using a range of treatmentdevices and modalities as described in more detail below. In preferredembodiments, the temperature and duration of the heat treatment areselected to affect physical characteristics of tissues, reduce cellproliferation and/or treat infection but not to kill tissues of thepneumostoma.

Methods of cryotherapy include placing the target tissues in thermalcontact with a cooled device or medium to lower the temperature of thetarget tissue. Cryotherapy may be used in two modes. The first mode ofcryotherapy is cryogenic ablation in which cryotherapy is used to freezetissue. A device is used to lower the temperature of the target cells totemperatures below freezing for short periods of time. The cells in thefrozen tissue die and the tissue is removed. However, it is adisadvantage of tissue ablation that the cell necrosis stimulates thehealing response. The healing response causes cell proliferation andgeneration of more cells in the form of scar tissue. As a result,cryogenic ablation may ultimately lead to greater tissue encroachmentrather than less tissue encroachment. Cryogenic ablation may howeverstill be useful for treating regions where tissue is encroaching intothe pneumostoma.

A second mode of cryotherapy is cryogenic cooling in which cells arecooled below physiologic temperatures without freezing the cells. Adevice is used to lower the temperature of the target cells totemperatures between normal physiologic temperatures and a temperatureabove freezing for short periods of time. Cryogenic cooling has beenfound to reduce hyperplasia in blood vessels. See e.g. U.S. Pat. No.6,811,550 entitled “Safety Cryotherapy Catheter” to Holland et al.Cryogenic cooling may also be used to his mode of cryotherapy to treatlarger areas of the pneumostoma including up to the entire pneumostoma.In preferred embodiments, the temperature and duration of thecryotherapy are selected to affect physical characteristics of tissues,reduce cell proliferation and/or treat infection but not to kill tissuesof the pneumostoma.

FIGS. 8A-8C show a catheter which may be used for cryotherapy orthermotherapy of a pneumostoma tissues. As shown in FIG. 8A, catheter800 includes a shaft 802, a balloon 804 and a flange 806. Flange 806slides on the exterior of shaft 802 and acts as a mechanical stop forinsertion of shaft 802 into a pneumostoma. The positioning of flange 806on shaft 802 allows the physician to control the depth of balloon 804and thus the location of the treatment area. The shaft 802 is providedwith external markings 805 to indicate the distance between thetreatment area and flange 806 thereby facilitating application of thetreatment to the desired target tissues.

As shown in FIG. 8B, shaft 802 has two lumens in inner lumen 808 andouter lumen 810. In some embodiments shaft 802 may be coated with aninsulating layer 803 so that treatment is limited to the region of theballoon 804. The balloon may then be moved to different locations in thepneumostoma to treat different areas. In other embodiments, shaft 802 isnot insulated and is also designed to treat the tissues of thepneumostoma in addition to the balloon. In such cases, it is preferablethat treatment is performed at a single position (because to dootherwise would treat areas along the shaft 802 multiple times). Asshown in FIG. 8C, at the proximal end of shaft 802 are an inlet 809which communicates with inner lumen 808 and an outlet 811 whichcommunicates with outer lumen 810.

As used for cryotherapy, catheter 800 is introduced in to thepneumostoma 110 to a depth limited by flange 806 as shown in FIG. 8C.Cryotherapy catheter 800 is connected to a cryotherapy coolant system819 which supplies a temperature-controlled coolant fluid to cryotherapycatheter 800. A coolant fluid is introduced through inlet 809 into innerlumen 808. The coolant passes through inner lumen 808 to the distal endof cryogenic catheter 800. The coolant passes through an aperture out ofinner lumen 808 into the balloon 804. The coolant inflates balloon 804to bring it into contact with the tissue of the pneumostoma 110. Thecoolant circulates around balloon 804 and cools the surface of balloon804 to the desired temperature. The coolant then returns through theouter lumen 810 and exits the catheter via the outlet 811. In someembodiments, a temperature sensor may be included in the distal tip ofcryotherapy catheter 800 in order to monitor the temperature of theballoon. However, in other embodiments, temperature regulation isperformed by regulating the temperature of the coolant supplied by thecryotherapy coolant system.

The coolant fluid is preferably a non-toxic liquid such as saline.However, liquids other than saline may be used and in some cases thecoolant fluid may be a temperature-controlled gas. One system forsupplying coolant is described in U.S. Pat. No. 6,432,102 entitled“Cryosurgical Fluid Supply” to Joye et al. If thermotherapy of thetissues is desired, a fluid heated to above body-temperature may be usedin place of the coolant.

FIG. 8D shows an alternative cryotherapy probe 820. Cryotherapy probe820 includes a shaft 821 and tip 822. Tip 822 is of fixed size and ispreferably made of a heat conductive material. Tip 822 may be made inwhole or in part of a biocompatible metal, for example surgical steel.Tip 822 may be made in one piece with shaft 821 or may be madeseparately and joined to shaft 821. As shown in FIG. 8E, shaft 821(shown in FIG. 8D) includes two lumens 824, 826 for supplying coolant totip 822 (in FIG. 8D). Tip 822 has a cavity 828 in which the coolantcirculates. At the proximal end of cryotherapy probe 820 is an inlet 834which communicates with lumen 824 and an outlet 836 which communicateswith lumen 826. In some embodiments, shaft 820 may be coated with aninsulating layer 823 so that treatment is limited to the region of thetip 822. Shaft 821 may be coated with an insulating material 823 inorder that the cryotherapy treatment is localized to the region of tip822. The tip 822 may then be moved to different locations in thepneumostoma to treat different areas.

The size of tip 822 may differ between different cryotherapy probes 820.A physician may have a range of cryotherapy probes available and choosethe cryotherapy probe based upon the anatomy of the pneumostoma and thesize and location of the tissues to be treated. Cryotherapy probe 820may optionally be provided with a flange 830 positionable along shaft821 in order to limit insertion of tip 822 into the pneumostoma andthereby control the location of tip 822 and the location of thecryotherapy treatment site.

In use, cryotherapy probe 820 is introduced into a pneumostoma to aposition indicated by the markings on the exterior of the shaft 821 orposition of the flange 830. Tip 822 is brought into thermal contact withthe pneumostoma tissues to be treated. Cryotherapy probe 820 isconnected to a cryotherapy coolant system 819. A coolant fluid isintroduced through inlet 834 into lumen 824. The coolant passes throughlumen 824 to the distal end of cryotherapy probe 820. The coolant passesthrough an aperture out of lumen 824 into the cavity 828. The coolantcirculates around cavity 828 and cools the surface of tip 822 to thedesired temperature. The coolant then returns through lumen 826 andexits the probe via the outlet 836. In some embodiments a temperaturesensor may be included in the tip 822 of cryotherapy probe 820 in orderto monitor the temperature of the tip. However, in other embodiments,temperature regulation is performed by regulating the temperature of thecoolant supplied by the cryotherapy coolant system. For thermotherapy, aheated fluid may be circulated through the probe in place of thecoolant.

Pneumostoma Treatment Using Electromagnetic Radiation

The treatment modalities available for treating a pneumostoma includethe application of energy in the form of electromagnetic radiation, forexample, infrared, ultraviolet, visible light, RF, microwaves. Suchenergy treatment can be used to affect physical characteristics oftissues and cell proliferation and also to treat infection. For example,the tissues of the pneumostoma tend to encroach into the lumen of thepneumostoma and/or thicken the walls of the pneumostoma therebyimpairing the function of the pneumostoma. One way to reduce tissueencroachment and/or thickness is through the application of energy tothe tissues, either to kill the cells or to reduce their proliferationthereby maintaining or enhancing the patency of the pneumostoma. In someembodiments a pneumostoma treatment device may be used to direct energyto particular localized regions of the pneumostoma tissue, in otherembodiments, the pneumostoma treatment device may apply energy equallyin all directions. In other embodiments, the electromagnetic radiationmay be selected to kill or damage bacteria to reduce infection whileminimizing damage to the cells of the pneumostoma. Some frequencies ofvisible light, for example, have been shown to kill certain bacteriawithout causing significant damage to human cells.

FIG. 9A illustrates a pneumostoma treatment device 900 for treatment ofpneumostoma tissues with electromagnetic radiation. The device includesa shaft 902 having at its distal end a treatment head 904. The treatmenthead has a tapered or rounded tip 920 to facilitate introduction intothe pneumostoma. The treatment head 904 may generate electromagneticradiation in situ, or the electromagnetic radiation may be transmittedfrom an external source to the treatment head 904. The treatment headmay in some cases have a window 905 which is either open or covered witha material transparent to the electromagnetic radiation to betransmitted. In other cases the entire treatment head 904 may beenclosed in a material which is transparent to the deliveredelectromagnetic radiation.

At the proximal end the pneumostoma treatment device 900 has a coupling912 for connecting the pneumostoma treatment device 900 to a powersource which may provide the electromagnetic radiation directly orprovide electrical power to create electromagnetic radiation in thetreatment head 904. Coupling 912 may be connected to shaft 910 by aflexible cable 914. The proximal end of shaft 902 may also provideaccess to lumens 916 which communicate with apertures 918 adjacenttreatment head 904. Lumens 916 and apertures 918 optionally providesuction, irrigation and/or cooling to the region adjacent treatment head904 as necessary and/or desirable for a particular treatment modality.

The shaft 902 and treatment head 904 are of suitable diameter forinsertion into a pneumostoma. Typically the shaft 902 and treatment head904 will be less than approximately 10 mm in diameter. In some cases theshaft and treatment head may be approximately 5 mm in diameter. Theshaft 902 is flexible enough to allow insertion of the treatment head904 into a pneumostoma even when the pneumostoma is not entirelystraight. The shaft 902 should however be stiff enough that it canprovide adequate force to push the treatment head 904 to the correctlocation in the pneumostoma.

The pneumostoma treatment device carries a flange 906 which can slide onshaft 902. The flange 906 has a locking collar 908 to fix the flange 906at an adjustable position along the shaft 902, other locking means maybe used, for example, a suture, tape glue or mechanical lock. Thephysician will typically adjust the location of the flange 906 along theshaft 902 so that when the treatment head 904 and shaft 902 are insertedto the desired depth into a pneumostoma, the flange contacts the chestof the patient and prevent further insertion. Correct pre-positioning ofthe flange 906 on shaft 902 serves to guide treatment depth and protectagainst over insertion. The shaft 902 may also be provided with externalmarkings 910 so that the physician may determine the correct locationfor flange 906 and the corresponding depth of treatment head 904.

FIG. 9B shows a sectional view of pneumostoma treatment device 900inserted into a pneumostoma 110. Note that flange 906 is in contact withthe skin 114 of the chest 100 of the patient and thus acts as amechanical stop to prevent further insertion. Flange 906 mayadditionally be provided with an adhesive (not shown) to temporarilysecure the flange 906 to the skin 114 of the chest 100 of the patientthereby securing the treatment head 904 at the desired depth within thepneumostoma 110. Coupling 912 connects controller 922 via cable 914 tothe proximal end of shaft 902 and via shaft 902 to treatment head 904.Controller 922 may be used to control the provision of electromagneticradiation by treatment head 904. Controller may control one or more of:the location, intensity, wavelength and/or duration of the applicationof the electromagnetic radiation as directed by a physician.

The treatment head 904 may be designed so that it deliverselectromagnetic radiation equally in all directions thereby treatinguniformly all of the tissues adjacent the treatment head. In alternativeembodiments treatment head 904 may be designed such that it applies theelectromagnetic radiation in a directional manner—this adds additionalcomplexity in that a mechanism needs to be provided for aligning theelectromagnetic radiation with the target tissues. However, thedirectional solution allows for different tissues within the pneumostomato be treated differently and also different regions to be treateddifferently from other regions. Directionality may be provided, forexample, using scanning optics to aim a beam of electromagneticradiation provided by controller 922 through a fiber optic cable.

FIG. 9C shows a sectional view of a pneumostoma treatment device 930 fortreatment of pneumostoma tissues with electromagnetic radiation. Thedevice includes a shaft 932 having at its distal end a treatment head934. The shaft 932 carries a flange 936 which can slide on shaft 932.One or more lumens 946 passes along the length of shaft 932 to one ormore aperture 948 adjacent treatment head 934. Lumens 946 and apertures948 optionally provide suction, irrigation and/or cooling to the regionadjacent treatment head 934 as necessary and/or desirable to enhancetreatment or protect tissue during treatment. At the proximal end thepneumostoma treatment device 930 has a coupling 942 for connecting thepneumostoma treatment device 930 to a power source 940 which provideselectrical power through cable 944 to create electromagnetic radiationin the treatment head 934.

In the embodiment shown in FIG. 9C, the treatment head 934 generateselectromagnetic radiation in situ. The treatment head 934 is enclosed ina material which is transparent to the delivered electromagneticradiation. As shown in FIG. 9C the treatment head 934 radiateselectromagnetic radiation in all directions uniformly from source 935located within head 934. Source 935, generates the desiredelectromagnetic radiation from electrical power provided by power source940. The source may be for example, a source of IR, UV visible light,X-rays or other electromagnetic radiation with which it is desired totreat the tissue of the pneumostoma. Particular devices suitable for useas source 935 include for example incandescent light sources, LEDs,fluorescent lamps and miniature X-ray sources. The source may beprovided with additional features to ensure uniformity of distributionof the selected electromagnetic radiation including, for example acollimator, diffuser, and or reflector.

FIG. 9D shows a sectional view of a pneumostoma treatment device 950 fortreatment of pneumostoma tissues with electromagnetic radiation. Thedevice includes a shaft 952 having at its distal end a treatment head954. The shaft 952 carries a flange 956 which can slide on shaft 952.Flange 956 may be locked to shaft 952 and secured to the chest of thepatient so that head 954 may be secured in a fixed relation to thepneumostoma during operation of pneumostoma treatment device 950. At theproximal end the pneumostoma treatment device 950 has a coupling 962 forconnecting the pneumostoma treatment device 950 to a controller 960which provides light and power through cable 964 to treatment head 954.

In the embodiment shown in FIG. 9D, the treatment head 954 does notgenerate electromagnetic radiation in situ. Instead, the electromagneticradiation is generated by controller 960 and transmitted through anoptical fiber 953 to treatment head 954. The treatment head 954 isenclosed in a material which is transparent to the deliveredelectromagnetic radiation. As shown in FIG. 9D, the treatment head 954includes scanning optics 958 which direct the electromagnetic radiationin a particular direction under the control of controller 960.Controller 960 generates the desired electromagnetic radiation,transmits it to head 954 which directs it to a particular region oftissue of the pneumostoma. Controller 960 is connected to a computersystem 964 which provides the physician with an interface 966 to operatecontroller 960 and control head 954 to treat selected target tissueswithin a pneumostoma.

Controller 960 may generate one or more selectable frequencies ofelectromagnetic radiation. Controller 960 may, for example include atunable laser source cable of generating coherent light over a range ofdifferent frequencies. The light frequency and intensity may be selectedbased upon the effect desired. For example, in some case the lightfrequency and intensity may be selected to ablate certain target tissuesin the pneumostoma. Tissue ablation may be used to generate pores in thewall of the pneumostoma to enhance patency of the pneumostoma and/orrestore pathways for gas to exit the pneumostoma.

In some embodiments, the scanning optics may also receive light receivedback from the tissue, which light may pass back down the fiber optic tocontroller 960. The received light may be analyzed using tissuespectroscopy and/or tomography techniques to determine properties of theparticular tissue from which the light is received. In such way the head954 can be used to analyze the tissue of the pneumostoma in addition to,or instead of, treating the tissue. Tissue scanning may be used in orderto select target tissues for e.g. ablation to enhance the selectivity oftreatment and reduce damage to sensitive tissue. For example, tissuescanning may be used to ensure that tissue ablation avoids blood vesselsin proximity to the pneumostoma when forming pores to restore or enhancethe exit of gas through the pneumostoma.

Because of the proximity of blood vessels to the surface of thepneumostoma, the pneumostoma may also be used as a port for analysis ofcompounds in the bloodstream. For example analysis of blood gases,and/or glucose concentration. The analysis can be performed by scanningthe thin tissues of the pneumostoma and analyzing the light receivedfrom the tissues. Information in the received light at differentfrequencies and in a number of modes (for example scattering,reflectance, absorption and fluorescence) may be used to derive detailedinformation regarding the tissues of the pneumostoma and blood invessels immediately adjacent the pneumostoma

The foregoing description of preferred embodiments of the presentinvention has been provided for the purposes of illustration anddescription. It is not intended to be exhaustive or to limit theinvention to the precise forms disclosed. Many embodiments were chosenand described in order to best explain the principles of the inventionand its practical application, thereby enabling others skilled in theart to understand the invention for various embodiments and with variousmodifications that are suited to the particular use contemplated.Embodiments of the present invention may use some or all of the featuresshown in the various disclosed embodiments where such features are notstructurally or functionally incompatible. It is intended that the scopeof the invention be defined by the claims and their equivalents.

1. A method for treating a pneumostoma into a lung of a patientcomprising; (a) removing a pneumostoma management device from thepneumostoma; (b) inserting the treatment part of a pneumostoma treatmentinstrument into the pneumostoma; (c) treating the pneumostoma with thetreatment part so as to maintain and/or enhance escape of gases from thelung through the pneumostoma; (d) removing the treatment part of thepneumostoma treatment instrument from the pneumostoma; and (e) insertinga pneumostoma management device into the pneumostoma.
 2. The method ofclaim 1, wherein the method steps are performed in the order of (a),(b), (c), (d) then (e).
 3. The method of claim 1, further comprising:(f) selecting a pneumostoma treatment instrument for treating thepneumostoma prior to step (b).
 4. The method of claim 1, furthercomprising: (f) determining a dimension of the pneumostoma; and (g)configuring the pneumostoma treatment instrument based on the dimensionof the pneumostoma prior to step (b).
 5. The method of claim 1, furthercomprising: (f) selecting a portion of a tissue of the pneumostoma beingless than all of the tissue of the pneumostoma to treat with thetreatment part; wherein step (b) comprises inserting the treatment partof the pneumostoma treatment instrument into the pneumostoma so as totreat a portion of tissue of the pneumostoma selected in step (f); and,wherein step (c) comprises treating the portion of tissue of thepneumostoma selected in step (f) with the pneumostoma treatment part soas to maintain and/or enhance the escape of gases from the lung throughthe pneumostoma without treating other tissue of the pneumostoma withthe treatment part.
 6. The method of claim 1, further comprising thestep of: (f) applying one or more of suction and irrigation to thepneumostoma.
 7. The method of claim 1, further comprising the step of(f) applying one or more of suction and irrigation to the pneumostomaafter step (c) and before step (e).
 8. The method of claim 1, whereinthe pneumostoma treatment device comprises an energy source and whereinthe method comprises: (c) applying energy to the pneumostoma with thetreatment part so as to maintain and/or enhance the escape of gases fromthe lung through the pneumostoma.
 9. The method of claim 1, wherein thepneumostoma treatment device comprises an electromagnetic energy sourceand wherein the method comprises: (c) applying electromagnetic energy tothe pneumostoma with the treatment part so as to maintain and/or enhancethe escape of gases from the lung through the pneumostoma.
 10. Themethod of claim 1, wherein the pneumostoma treatment device comprises asound source, wherein the sound source supplies one or more ofinfrasound, acoustic sound and infrasound and wherein the methodcomprises: (c) applying sound to the pneumostoma with the treatment partso as to maintain and/or enhance the escape of gases from the lungthrough the pneumostoma.
 11. The method of claim 1, wherein thepneumostoma treatment part comprises a temperature-controlled surfaceand wherein the method comprises: (b) inserting the treatment part ofthe pneumostoma treatment instrument into the pneumostoma so as to bringthe temperature-controlled surface into contact with a tissue of thepneumostoma; and (c) treating the tissue of the pneumostoma with thetreatment part by changing the temperature of the tissue away from bodytemperature for a selected period of time so as to maintain and/orenhance the escape of gases from the lung through the pneumostoma. 12.The method of claim 1, wherein the pneumostoma treatment part comprisesa temperature-controlled surface and wherein the method comprises: (b)inserting the treatment part of the pneumostoma treatment instrumentinto the pneumostoma so as to bring the temperature-controlled surfaceinto contact with a tissue of the pneumostoma; and (c) treating thetissue of the pneumostoma with the temperature-controlled surface of thetreatment part by cooling the tissue to a temperature lower than bodytemperature for a selected period of time so as to maintain and/orenhance the escape of gases from the lung through the pneumostoma.
 13. Amethod for treating a tissue of a surgically-created passage whichpasses through a thoracic wall, parietal membrane and visceral membraneinto a lung of a patient and through which gasses may escape from thelung, the parietal membrane being sealed to the visceral membranesurrounding the passage, wherein the method comprises; (a) selecting atreatment device having a treatment probe; (b) inserting the treatmentprobe of the treatment device into the passage; (c) treating a tissue ofthe passage with the treatment probe; (d) removing the treatment probefrom the passage; and (e) inserting a tube into the passage throughwhich gases may escape the lung via the chest wall.
 14. The method ofclaim 13, wherein step (c) comprises treating a tissue of the passagewith the treatment probe to enhance escape of gases from the lungthrough the passage.
 15. The method of claim 13, wherein the methodsteps are performed in the order (a) (b) (c) (d) (e).
 16. The method ofclaim 13, further comprising: (f) determining a dimension of thepassage; and (g) configuring the treatment device based on the dimensionof the passage prior to step (b).
 17. The method of claim 13, furthercomprising: (f) selecting a tissue of the passage being less than all ofthe tissue of the passage to treat with the treatment device; andwherein step (c) comprises selectively treating the portion of a tissueof the passage selected in step (f) with the treatment probe withouttreating other tissues of the passage with the treatment part.
 18. Themethod of claim 13, further comprising the step of (f) applying one ormore of suction and irrigation to the passage after step (b) and beforestep (e).
 19. The method of claim 13, wherein the treatment devicecomprises a means for transmitting energy and wherein the methodcomprises: (c) applying energy to a tissue of the passage with thetreatment probe.
 20. The method of claim 13, wherein the treatment probecomprises a coolable surface and wherein the method comprises: (b)inserting the treatment probe into the passage so as to bring thecoolable surface into contact with a tissue of the passage; and (c)treating the tissue of the passage with the coolable surface of thetreatment part by cooling the tissue to a temperature lower than bodytemperature for a selected period of time.
 21. A method for treating atissue of a stoma which passes through a thoracic wall, parietalmembrane and visceral membrane into a lung of a patient and throughwhich gasses may escape from the lung, the parietal membrane beingsealed to the visceral membrane surrounding a passage, wherein themethod comprises; (a) selecting a treatment device having a treatmentprobe; (b) measuring a dimension of the stoma; (c) configuring thetreatment probe in response to the dimension of the stoma; (d) insertingthe treatment probe into the stoma; (e) treating a tissue of the stomawith the treatment probe so as to promote the escape of gases from thelung through the stoma; and (f) removing the treatment probe from thestoma.
 22. The method of claim 21 further comprising: (g) selecting somebut not all of the tissue of the stoma to treat with the treatment probeso as to promote the escape of gases from the lung through the stoma;and wherein step (c) comprises selectively treating the some but not allof the tissue of the stoma selected in step (g) with the treatment probeso as to promote the escape of gases from the lung through the stoma.23. The method of claim 21, further comprising the step of (g) removinga material from the stoma.
 24. The method of claim 21, furthercomprising: (g) inserting a tube into the stoma through which gases mayescape the lung via the chest wall.
 25. The method of claim 21, whereinthe treatment device comprises a means for transmitting energy andwherein the method comprises: (c) applying energy to a tissue of thestoma with the treatment probe.